Basic Information
| Provider Information | |||||||||
| NPI: | 1275617839 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRENTISS | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1870 W GALENA BLVD | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605064356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308596700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1221 N HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605061404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308598700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 11/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 01074235A | IN | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | K8818 | TX | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 036-096029 | IL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 036096029 | 05 | IL | MEDICAID | K8818 | 01 | TX | LICENSE NUMBER | OTHER | 01074235A | 01 | IN | LICENSE NUMBER | OTHER | 04515143 | 01 | IL | BCBS# | OTHER | 7258113 | 01 | TX | AETNA PROVIDER NUMBER | OTHER | 0072GK | 01 | TX | BCBS PROVIDER NUMBER | OTHER |