Basic Information
| Provider Information | |||||||||
| NPI: | 1881899276 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ISAAC | ||||||||
| FirstName: | PRASANNA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 W 22ND ST | ||||||||
| Address2: | |||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605231557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083861000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7836 W JEFFERSON BLVD STE 101 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468044178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604943484 | ||||||||
| FaxNumber: | 2604715507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2007 | ||||||||
| LastUpdateDate: | 05/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 01067936A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | 35.095468 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 1021263090001 | 05 | PA | MEDICAID | 1012980 | 05 | LA | MEDICAID | 200977120 | 05 | IN | MEDICAID |