Provider Demographics
NPI:1831301282
Name:CROSS, DAVID T
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:T
Last Name:CROSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19248
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9248
Mailing Address - Country:US
Mailing Address - Phone:217-528-7541
Mailing Address - Fax:217-525-7616
Practice Address - Street 1:134 W ADAMS ST
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-1802
Practice Address - Country:US
Practice Address - Phone:217-528-7541
Practice Address - Fax:309-676-6545
Is Sole Proprietor?:No
Enumeration Date:2007-05-05
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036118871208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036118871Medicaid
ILK39373Medicare PIN