Provider Demographics
NPI:1124330055
Name:LASSUS, DONALD BENJAMIN (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:BENJAMIN
Last Name:LASSUS
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 1:1701 W. SUPERIOR
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622
Mailing Address - Country:US
Mailing Address - Phone:312-666-3494
Mailing Address - Fax:312-432-4354
Practice Address - Street 1:4747 N. KEDZIE AVENUE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625
Practice Address - Country:US
Practice Address - Phone:312-666-3494
Practice Address - Fax:773-267-2175
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036135721207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036135721Medicaid
IL036-135721OtherIL LIC
ILF400260092Medicare UPIN