Provider Demographics
NPI:1477605913
Name:DONAHUE, GRETTEL C (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:GRETTEL
Middle Name:C
Last Name:DONAHUE
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:DR
Other - First Name:GRETTEL
Other - Middle Name:C
Other - Last Name:JARA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1111 W LAKE ST
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-1101
Mailing Address - Country:US
Mailing Address - Phone:630-628-1811
Mailing Address - Fax:630-628-1501
Practice Address - Street 1:1111 W LAKE ST
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-1101
Practice Address - Country:US
Practice Address - Phone:630-628-1811
Practice Address - Fax:630-628-1501
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036108129261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036108129Medicaid
ILI09068Medicare UPIN
IL036108129Medicaid