Provider Demographics
NPI:1952399396
Name:DUA, PREM (MD)
Entity Type:Individual
Prefix:DR
First Name:PREM
Middle Name:
Last Name:DUA
Suffix:
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 1:13939 REFLECTION CT
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-8026
Mailing Address - Country:US
Mailing Address - Phone:636-527-2829
Mailing Address - Fax:
Practice Address - Street 1:1315 LEHMEN DR
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:IL
Practice Address - Zip Code:62233-0031
Practice Address - Country:US
Practice Address - Phone:618-826-4571
Practice Address - Fax:618-826-3229
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-4163567208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP15529Medicare ID - Type Unspecified
E24659Medicare UPIN