Provider Demographics
NPI:1720071129
Name:GREATHOUSE, DAVID J (DO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:GREATHOUSE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 DOCTORS LN
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-3369
Mailing Address - Country:US
Mailing Address - Phone:309-836-3387
Mailing Address - Fax:309-833-1023
Practice Address - Street 1:5 DOCTORS LN
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3369
Practice Address - Country:US
Practice Address - Phone:309-836-3387
Practice Address - Fax:309-833-1023
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078513207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036078513Medicaid
L67128Medicare ID - Type Unspecified
IL036078513Medicaid