Provider Demographics
NPI:1710907142
Name:PROHAZKA, DONNA (MD)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:PROHAZKA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N OAK AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-5703
Mailing Address - Country:US
Mailing Address - Phone:715-387-5511
Mailing Address - Fax:
Practice Address - Street 1:1000 N OAK AVE
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-5703
Practice Address - Country:US
Practice Address - Phone:715-387-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1175022085B0100X, 2085R0202X, 2085U0001X
WI530212085R0202X, 2085B0100X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203840202Medicaid
75030OtherHEALTH ALLIANCE
11377OtherESSENCE
300092272OtherMEDICARE RAILROAD MO
250846OtherHARMONY ID NUMBER
5106488OtherAETNA
1853OtherBLUE CROSS BLUE SHIELD
434759OtherHEALTHLINK
1853OtherBLUE CROSS BLUE SHIELD
MO203840202Medicaid
75030OtherHEALTH ALLIANCE