Provider Demographics
NPI:1003039645
Name:RILEY, TODD ROGER (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:ROGER
Last Name:RILEY
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 1:1 UNIVERSITY PLZ
Mailing Address - Street 2:
Mailing Address - City:PLATTEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53818-3001
Mailing Address - Country:US
Mailing Address - Phone:608-342-1891
Mailing Address - Fax:608-342-1028
Practice Address - Street 1:1 UNIVERSITY PLZ
Practice Address - Street 2:
Practice Address - City:PLATTEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53818-3001
Practice Address - Country:US
Practice Address - Phone:608-342-1891
Practice Address - Fax:608-342-1028
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30756-020208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIG49298Medicare UPIN