Provider Demographics
NPI:1780628388
Name:PENN, DONALD E JR (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:E
Last Name:PENN
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:PO BOX 365
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-0365
Mailing Address - Country:US
Mailing Address - Phone:309-672-4980
Mailing Address - Fax:309-671-2944
Practice Address - Street 1:1001 MAIN ST
Practice Address - Street 2:SUITE 500A
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606
Practice Address - Country:US
Practice Address - Phone:309-672-4980
Practice Address - Fax:309-671-2944
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036062844207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371221637OtherFEDERAL TAX IDENTIFICATIO
IL07215152OtherBLUE CROSS
IL166330OtherHEALTHLINK
IL100004399OtherRAILROAD MEDICARE
ILIL0101OtherJOHN DEERE
IL4282553OtherAETNA HEALTH PLANS
IL008850OtherHEALTH ALLIANCE
IL036062844Medicaid
IL776530OtherMEDICARE GROUP NUMBER
IL4282553OtherAETNA HEALTH PLANS
IL100004399OtherRAILROAD MEDICARE