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General NPI Number Information
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NPI Number | 1316028723
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Entity Type | Individual
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Provider Name | LORETTA L DE KOSTER O.D.
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Gender | Female
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Dates
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Enumeration Date | 10/19/2006
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Last Update Date | 07/05/2018
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Provider Practice Location Address
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Address Line | 2500 N. HARLEM AVE
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City | ELMWOOD PARK
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State | IL
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Zip | 60707-2020
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Country | US
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Telephone | 708-456-4362
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Fax | 708-456-5161
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Provider Business Mailing Address
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Address Line | 2500 N. HARLEM AVE
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City | ELMWOOD PARK
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State | IL
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Zip | 60707-2020
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Country | US
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Telephone | 708-456-4362
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Fax | 708-456-5161
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 046008683
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 046.008683
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License Number State | IL
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