Basic Information
| Provider Information | |||||||||
| NPI: | 1063500403 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FIFE | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2405 SE 17TH ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344719190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526902171 | ||||||||
| FaxNumber: | 3526906954 | ||||||||
| Practice Location | |||||||||
| Address1: | 4225 NW AMERICAN LN | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320558841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867586141 | ||||||||
| FaxNumber: | 3867586140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 08/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 9485 | ND | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | ME131605 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 12094 | 05 | ND | MEDICAID |