Provider Demographics
NPI:1386600039
Name:DAVALLE, MICHAEL J (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:DAVALLE
Suffix:
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 1:2650 WARRENVILLE RD
Mailing Address - Street 2:STE 280
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515
Mailing Address - Country:US
Mailing Address - Phone:630-324-7916
Mailing Address - Fax:630-324-7946
Practice Address - Street 1:2650 WARRENVILLE RD
Practice Address - Street 2:STE 280
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515
Practice Address - Country:US
Practice Address - Phone:630-324-7916
Practice Address - Fax:630-324-7946
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360663122086S0129X, 208G00000X
IN01055379A2086S0129X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36066316Medicaid
526620OtherCOOK GROUP
344390OtherDU PAGE GROUP
344390OtherDU PAGE GROUP
526620OtherCOOK GROUP
C48349Medicare UPIN