Provider Demographics
NPI:1053398933
Name:FORD, DONALD R (MD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:R
Last Name:FORD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:600 N COLLEGE AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:GENESEO
Mailing Address - State:IL
Mailing Address - Zip Code:61254-1091
Mailing Address - Country:US
Mailing Address - Phone:309-944-5342
Mailing Address - Fax:309-945-4079
Practice Address - Street 1:600 N COLLEGE AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:GENESEO
Practice Address - State:IL
Practice Address - Zip Code:61254-1091
Practice Address - Country:US
Practice Address - Phone:309-944-5342
Practice Address - Fax:309-944-8192
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA25736207Q00000X
IL036047661207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360476613Medicaid
IL0801777765OtherRR MEDICARE
IL1053398933Medicaid
IL036047661Medicaid
IL0360476613Medicaid
IL0801777765OtherRR MEDICARE
IL1053398933Medicaid