Provider Demographics
NPI:1275617839
Name:PRENTISS, DONALD PAUL JR (MD)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:PAUL
Last Name:PRENTISS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1870 W GALENA BLVD
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-4356
Mailing Address - Country:US
Mailing Address - Phone:630-859-6700
Mailing Address - Fax:
Practice Address - Street 1:1221 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-1404
Practice Address - Country:US
Practice Address - Phone:630-859-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01074235A208600000X
TXK8818208600000X
IL036-096029208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036096029Medicaid
TXK8818OtherLICENSE NUMBER
IN01074235AOtherLICENSE NUMBER
IL04515143OtherBCBS#
TX7258113OtherAETNA PROVIDER NUMBER
TX0072GKOtherBCBS PROVIDER NUMBER
IL036096029Medicaid
IL390362030Medicare PIN
TXK8818OtherLICENSE NUMBER
TX7258113OtherAETNA PROVIDER NUMBER
TX0072GKOtherBCBS PROVIDER NUMBER