Basic Information
Provider Information | |||||||||
NPI: | 1114033867 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TODD | ||||||||
FirstName: | WILLIAM | ||||||||
MiddleName: | DOUGLAS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 85 SIERRA PARK RD | ||||||||
Address2: | POST OFFICE BOX 660 | ||||||||
City: | MAMMOTH LAKES | ||||||||
State: | CA | ||||||||
PostalCode: | 935462073 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7609343311 | ||||||||
FaxNumber: | 7609244029 | ||||||||
Practice Location | |||||||||
Address1: | 221 TWIN LAKES ROAD | ||||||||
Address2: |   | ||||||||
City: | BRIDGEPORT | ||||||||
State: | CA | ||||||||
PostalCode: | 935170535 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7609327011 | ||||||||
FaxNumber: | 7609327180 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/22/2006 | ||||||||
LastUpdateDate: | 03/05/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA12095 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.