Healthcare Provider Details

I. General information

NPI: 1902096928
Provider Name (Legal Business Name): JOSHUA BRADLEY KENTOSH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 07/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4909 N. GLEN PARK PLACE
PEORIA IL
61614-4676
US

IV. Provider business mailing address

4909 N. GLEN PARK PLACE
PEORIA IL
61614-4676
US

V. Phone/Fax

Practice location:
  • Phone: 309-674-7546
  • Fax: 309-691-9286
Mailing address:
  • Phone: 309-674-7546
  • Fax: 309-282-2075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036.142442
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number036.142442
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number036.142442
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: