Basic Information
| Provider Information | |||||||||
| NPI: | 1407821820 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUNYAN | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 669 | ||||||||
| Address2: | |||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853662329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282476516 | ||||||||
| FaxNumber: | 6022163000 | ||||||||
| Practice Location | |||||||||
| Address1: | 11274 S FORTUNA RD STE I4 | ||||||||
| Address2: | |||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853677849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282476516 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2006 | ||||||||
| LastUpdateDate: | 03/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 27578 | AZ | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 474180 | 05 | AZ | MEDICAID |