Provider Demographics
NPI:1003804006
Name:POWERS, DAVID JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JOSEPH
Last Name:POWERS
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 1:102 S HENNEPIN AVENUE
Mailing Address - Street 2:KSB MEDICAL GROUP/TOWN SQUARE CENTER
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-0000
Mailing Address - Country:US
Mailing Address - Phone:815-288-1035
Mailing Address - Fax:815-284-0584
Practice Address - Street 1:215 E 1ST ST STE 315
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-3190
Practice Address - Country:US
Practice Address - Phone:815-288-1035
Practice Address - Fax:815-284-0584
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036082587208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL381220029OtherMEDICARE
IL036082587Medicaid
ILK07142Medicare ID - Type Unspecified