Healthcare Provider Details

I. General information

NPI: 1659940492
Provider Name (Legal Business Name): DAVID KORSAK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 N ASHLAND AVE
CHICAGO IL
60622-5149
US

IV. Provider business mailing address

845 N ASHLAND AVE
CHICAGO IL
60622-5149
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-0407
  • Fax:
Mailing address:
  • Phone: 312-942-0407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046.011509
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: