Provider Demographics
NPI:1982654240
Name:DAVIDSON, TIMOTHY A (DC)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:A
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 WILLOW CIRCLE DR
Mailing Address - Street 2:STE. #400
Mailing Address - City:CREST HILL
Mailing Address - State:IL
Mailing Address - Zip Code:60435-0959
Mailing Address - Country:US
Mailing Address - Phone:815-729-9922
Mailing Address - Fax:815-729-9933
Practice Address - Street 1:1640 WILLOW CIRCLE DR
Practice Address - Street 2:STE. #400
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60435-0959
Practice Address - Country:US
Practice Address - Phone:815-729-9922
Practice Address - Fax:815-729-9933
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL653965OtherACN GROUP
IL7643227OtherAETNA
IL653965OtherACN
IL12143864OtherMULTIPLAN
IL2115623OtherCAQH
IL9932155OtherBC/BS
ILP3297300Other1ST HEALTH
IL12143864OtherMULTIPLAN