Provider Demographics
NPI:1740290386
Name:KUELTZO, GLENN D (OD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:D
Last Name:KUELTZO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:13231 W 143RD ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-6638
Mailing Address - Country:US
Mailing Address - Phone:708-301-2020
Mailing Address - Fax:708-301-0884
Practice Address - Street 1:13231 W 143RD ST
Practice Address - Street 2:SUITE 101
Practice Address - City:HOMER GLEN
Practice Address - State:IL
Practice Address - Zip Code:60491-6638
Practice Address - Country:US
Practice Address - Phone:708-301-2020
Practice Address - Fax:708-301-0884
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0039940592OtherBCBS OF ILLINOIS
ILT37302Medicare UPIN
ILK25047Medicare PIN