Provider Demographics
NPI:1689651010
Name:PROHASKA, DENNIS W (D O)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:W
Last Name:PROHASKA
Suffix:
Gender:M
Credentials:D O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 S WABASH AVE
Mailing Address - Street 2:APT 1104
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-2903
Mailing Address - Country:US
Mailing Address - Phone:414-870-5178
Mailing Address - Fax:
Practice Address - Street 1:1516 S WABASH AVE
Practice Address - Street 2:APT 1104
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-2903
Practice Address - Country:US
Practice Address - Phone:414-870-5178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1610-023363A00000X
IL085-002276363A00000X, 207P00000X
IN02004880B2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41994500Medicaid
WI41994500Medicaid
WI$$$$$$$$$009OtherBLUE SHIELD
WI41994500Medicaid
IL701330003Medicare PIN
WI0081Medicare PIN
WI0018Medicare PIN