Basic Information
| Provider Information | |||||||||
| NPI: | 1750431870 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVISON | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6500 W 65TH ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606384962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084961515 | ||||||||
| FaxNumber: | 7084961788 | ||||||||
| Practice Location | |||||||||
| Address1: | 6500 W 65TH ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606384962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084961515 | ||||||||
| FaxNumber: | 7084951788 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 01/26/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 036059839 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036059839 | 05 | IL | MEDICAID |