Provider Demographics
NPI:1629063169
Name:DAVIS, TODD T (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:T
Last Name:DAVIS
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 1:103 N HAVEN RD
Mailing Address - Street 2:SUITE 7
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-2923
Mailing Address - Country:US
Mailing Address - Phone:630-832-2111
Mailing Address - Fax:630-832-5199
Practice Address - Street 1:103 N HAVEN RD
Practice Address - Street 2:SUITE 7
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-2923
Practice Address - Country:US
Practice Address - Phone:630-832-2111
Practice Address - Fax:630-832-5199
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036107390207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL009900257OtherBCBS PROVIDER #
IL036107390Medicaid
ILH78943Medicare UPIN
IL974040Medicare ID - Type UnspecifiedMEDICARE PROVIDER #