Provider Demographics
NPI:1972619526
Name:KETTERING, TODD OWEN (DO)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:OWEN
Last Name:KETTERING
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 FRANKLIN AVENUE, SUITE 250
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761
Mailing Address - Country:US
Mailing Address - Phone:309-268-2502
Mailing Address - Fax:309-268-5620
Practice Address - Street 1:1300 FRANKLIN AVENUE, SUITE 100
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761
Practice Address - Country:US
Practice Address - Phone:309-268-3761
Practice Address - Fax:309-268-5620
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007709207Q00000X
IL036.123240207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36123240Medicaid
OH2339713Medicaid
IL036-123240OtherSTATE LICENSE
H51805Medicare UPIN
IL36123240Medicaid