Healthcare Provider Details

I. General information

NPI: 1003925280
Provider Name (Legal Business Name): JOSHUA L. KORSGARDEN, O.D., LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 04/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

472 N STATE ROUTE 47 SUITE E
SUGAR GROVE IL
60554
US

IV. Provider business mailing address

139A GILLETT ST
SUGAR GROVE IL
60554-9323
US

V. Phone/Fax

Practice location:
  • Phone: 630-466-4646
  • Fax: 630-466-4848
Mailing address:
  • Phone: 630-650-2041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046009658
License Number StateIL

VIII. Authorized Official

Name: DR. JOSHUA L KORSGARDEN
Title or Position: PRESIDENT/OPTOMETRIST
Credential: O.D.
Phone: 630-650-2041