Provider Demographics
NPI:1871592378
Name:PRUSEK, DOROTHY T (MD)
Entity type:Individual
Prefix:DR
First Name:DOROTHY
Middle Name:T
Last Name:PRUSEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 N YORK ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-1607
Mailing Address - Country:US
Mailing Address - Phone:331-221-2900
Mailing Address - Fax:331-221-2733
Practice Address - Street 1:755 N YORK ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-1607
Practice Address - Country:US
Practice Address - Phone:331-221-2900
Practice Address - Fax:331-221-2733
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036081546207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036081546Medicaid
IL02232472OtherBLUE CROSS/BLUE SHIELD #
IL02232472OtherBLUE CROSS/BLUE SHIELD #
ILK05664Medicare ID - Type Unspecified