Provider Demographics
NPI:1902909492
Name:DAVID-RESTIVO, EMILIA B (MD)
Entity Type:Individual
Prefix:
First Name:EMILIA
Middle Name:B
Last Name:DAVID-RESTIVO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 MEMORIAL DR STE 210
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6751
Mailing Address - Country:US
Mailing Address - Phone:618-463-0649
Mailing Address - Fax:618-465-3390
Practice Address - Street 1:4 MEMORIAL DR STE 210
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002
Practice Address - Country:US
Practice Address - Phone:618-463-0649
Practice Address - Fax:618-465-3390
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006017929208000000X
IL036-116491208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXN6122OtherTX LICENSE
MO2006017929OtherMO LICENSE
IL036116491OtherLICENSE NUMBER