Provider Demographics
NPI:1740039908
Name:ELMORE, DONALD E
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:E
Last Name:ELMORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 NORTH TRL
Mailing Address - Street 2:
Mailing Address - City:HAWTHORN WOODS
Mailing Address - State:IL
Mailing Address - Zip Code:60047-7718
Mailing Address - Country:US
Mailing Address - Phone:224-623-4646
Mailing Address - Fax:
Practice Address - Street 1:1969 W OGDEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3765
Practice Address - Country:US
Practice Address - Phone:312-864-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-17
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.01331363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant