Provider Demographics
NPI:1083720775
Name:VONDERHEIDE, TODD E (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:E
Last Name:VONDERHEIDE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:739 N JEFFERSON ST
Mailing Address - Street 2:SUITE 22
Mailing Address - City:MASCOUTAH
Mailing Address - State:IL
Mailing Address - Zip Code:62258
Mailing Address - Country:US
Mailing Address - Phone:618-566-8810
Mailing Address - Fax:618-566-7121
Practice Address - Street 1:251 MARKET PLACE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:FREEBURG
Practice Address - State:IL
Practice Address - Zip Code:62243-1393
Practice Address - Country:US
Practice Address - Phone:618-539-0067
Practice Address - Fax:618-539-0288
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2010-10-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036093782207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093782Medicaid
IL382430Medicare ID - Type Unspecified
IL036093782Medicaid