Provider Demographics
NPI:1730274770
Name:HOLLANDSWORTH, DON LEROY (DO)
Entity type:Individual
Prefix:
First Name:DON
Middle Name:LEROY
Last Name:HOLLANDSWORTH
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 1:20110 GOVERNORS HWY
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1030
Mailing Address - Country:US
Mailing Address - Phone:708-747-7960
Mailing Address - Fax:
Practice Address - Street 1:4001 VOLLMER RD.
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1073
Practice Address - Country:US
Practice Address - Phone:708-481-8883
Practice Address - Fax:708-481-2917
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036042652207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036042652Medicaid
IL446751Medicare ID - Type Unspecified
ILC42623Medicare UPIN