Provider Demographics
NPI:1124103916
Name:LOESCH, JOHN ANTHONY (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ANTHONY
Last Name:LOESCH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 S VILLA AVE
Mailing Address - Street 2:3
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-2687
Mailing Address - Country:US
Mailing Address - Phone:630-833-6214
Mailing Address - Fax:
Practice Address - Street 1:25 S VILLA AVE
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:IL
Practice Address - Zip Code:60181-2650
Practice Address - Country:US
Practice Address - Phone:630-832-6783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008334152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD93882Medicare UPIN
ILL16166Medicare ID - Type Unspecified