=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629063169
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TODD T DAVIS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2005
-----------------------------------------------------
Last Update Date | 01/31/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 N HAVEN RD SUITE 7
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60126-2923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-832-2111
-----------------------------------------------------
Fax | 630-832-5199
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 N HAVEN RD SUITE 7
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60126-2923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-832-2111
-----------------------------------------------------
Fax | 630-832-5199
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 036107390
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------