Provider Demographics
NPI:1346227212
Name:BOVA, DAVIDE (MD)
Entity Type:Individual
Prefix:
First Name:DAVIDE
Middle Name:
Last Name:BOVA
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 1:2160 S FIRST AVE
Mailing Address - Street 2:101 1740 LOYOLA UNIVERSITY MEDICAL CENTER
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2160 S FIRST AVE
Practice Address - Street 2:101 1740 LOYOLA UNIVERSITY MEDICAL CENTER
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-216-9000
Practice Address - Fax:708-216-9033
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-30
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL360975302085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36097530Medicaid
IL596340Medicare ID - Type Unspecified
IL36097530Medicaid
H23541Medicare UPIN