Healthcare Provider Details

I. General information

NPI: 1689651010
Provider Name (Legal Business Name): DENNIS W PROHASKA D. O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 07/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 S WABASH AVE APT 1104
CHICAGO IL
60605-2903
US

IV. Provider business mailing address

1516 S WABASH AVE APT 1104
CHICAGO IL
60605-2903
US

V. Phone/Fax

Practice location:
  • Phone: 414-870-5178
  • Fax:
Mailing address:
  • Phone: 414-870-5178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1610-023
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-002276
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number085-002276
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number02004880B
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: