Provider Demographics
NPI:1992982169
Name:LORETTA DE KOSTER,O.D. INC.
Entity type:Organization
Organization Name:LORETTA DE KOSTER,O.D. INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:DE KOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:708-456-4362
Mailing Address - Street 1:2528 N HARLEM AVE
Mailing Address - Street 2:MAIN FLOOR
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60707-2046
Mailing Address - Country:US
Mailing Address - Phone:708-456-4362
Mailing Address - Fax:708-456-5161
Practice Address - Street 1:2528 N HARLEM AVE
Practice Address - Street 2:MAIN FLOOR
Practice Address - City:ELMWOOD PARK
Practice Address - State:IL
Practice Address - Zip Code:60707-2046
Practice Address - Country:US
Practice Address - Phone:708-456-4362
Practice Address - Fax:708-456-5161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2012-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008683152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01621057OtherBCBS
IL046008683Medicaid
ILIL4407OtherMEDICARE PTAN
IL01621057OtherBCBS
IL387240Medicare PIN