Provider Demographics
NPI:1104029867
Name:LADD F. KORESCH O.D., S.C.
Entity type:Organization
Organization Name:LADD F. KORESCH O.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LADD
Authorized Official - Middle Name:F
Authorized Official - Last Name:KORESCH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:262-248-4878
Mailing Address - Street 1:415 BROAD ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-1800
Mailing Address - Country:US
Mailing Address - Phone:262-248-4878
Mailing Address - Fax:262-248-1100
Practice Address - Street 1:415 BROAD ST
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-1800
Practice Address - Country:US
Practice Address - Phone:262-248-4878
Practice Address - Fax:262-248-1100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1228-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38556600Medicaid
WIT62469Medicare UPIN