Provider Demographics
NPI:1104953397
Name:HEWELL, TODD S III (MD)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:S
Last Name:HEWELL
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 W RIVER DR
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-5535
Mailing Address - Country:US
Mailing Address - Phone:630-377-1133
Mailing Address - Fax:630-584-4099
Practice Address - Street 1:260 W RIVER DR
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-5535
Practice Address - Country:US
Practice Address - Phone:630-377-1133
Practice Address - Fax:630-584-4099
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD15668Medicare UPIN
IL739100Medicare ID - Type Unspecified