Provider Demographics
NPI:1841255908
Name:GANDER, TODD W (DC)
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:W
Last Name:GANDER
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 1:407 E CENTER ST STE B
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:IL
Mailing Address - Zip Code:61530-1292
Mailing Address - Country:US
Mailing Address - Phone:309-467-4494
Mailing Address - Fax:
Practice Address - Street 1:407 E CENTER ST STE B
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:IL
Practice Address - Zip Code:61530-1292
Practice Address - Country:US
Practice Address - Phone:309-467-4494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-003957111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL660400OtherMEDICARE PTAN
ILT37578Medicare UPIN
IL660400Medicare UPIN