Basic Information
| Provider Information | |||||||||
| NPI: | 1962885012 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KORNAUS | ||||||||
| FirstName: | ANDREW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1025 REGENT ST | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082822000 | ||||||||
| FaxNumber: | 6082822068 | ||||||||
| Practice Location | |||||||||
| Address1: | 1025 REGENT ST | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082822000 | ||||||||
| FaxNumber: | 6082822068 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2015 | ||||||||
| LastUpdateDate: | 12/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3373-035 | WI | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1962885012 | 05 | WI | MEDICAID |