Provider Demographics
NPI:1881646636
Name:KORTH, KATHRYN ANN (OD, FAAO)
Entity type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:ANN
Last Name:KORTH
Suffix:
Gender:F
Credentials:OD, FAAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 E BYRD ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-3041
Mailing Address - Country:US
Mailing Address - Phone:920-830-3351
Mailing Address - Fax:
Practice Address - Street 1:1000 W NORTHLAND AVE
Practice Address - Street 2:SHOPKO OPTICAL
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-1419
Practice Address - Country:US
Practice Address - Phone:920-731-4511
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2441152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38586100Medicaid
WIU13920Medicare UPIN