Provider Demographics
NPI:1336403617
Name:OSTBLOOM, RENA KIRAN (OD)
Entity type:Individual
Prefix:
First Name:RENA
Middle Name:KIRAN
Last Name:OSTBLOOM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1456 AMBLESIDE CIR
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-0316
Mailing Address - Country:US
Mailing Address - Phone:630-338-5385
Mailing Address - Fax:
Practice Address - Street 1:1298 FOX VALLEY CTR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-4184
Practice Address - Country:US
Practice Address - Phone:630-851-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-01
Last Update Date:2012-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.010564152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist