Provider Demographics
NPI:1487116786
Name:KORTES, SAMUEL JON
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JON
Last Name:KORTES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 74008272
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-8272
Mailing Address - Country:US
Mailing Address - Phone:702-899-0595
Mailing Address - Fax:702-977-1496
Practice Address - Street 1:531 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-2531
Practice Address - Country:US
Practice Address - Phone:872-231-3162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-04
Last Update Date:2025-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI75951208100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program