Provider Demographics
NPI:1750431870
Name:DAVISON, DANIEL THOMAS (DO)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:THOMAS
Last Name:DAVISON
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 1:6500 W 65TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-4962
Mailing Address - Country:US
Mailing Address - Phone:708-496-1515
Mailing Address - Fax:708-496-1788
Practice Address - Street 1:6500 W 65TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-4962
Practice Address - Country:US
Practice Address - Phone:708-496-1515
Practice Address - Fax:708-495-1788
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036059839207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036059839Medicaid
IL036059839Medicaid
ILD13623Medicare UPIN