Provider Demographics
NPI:1003882200
Name:MCCLUSKEY, TODD D (DO)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:D
Last Name:MCCLUSKEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3308 W EDGEWOOD DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-6891
Mailing Address - Country:US
Mailing Address - Phone:573-893-7848
Mailing Address - Fax:573-893-1984
Practice Address - Street 1:3308 W EDGEWOOD DR
Practice Address - Street 2:SUITE B
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6891
Practice Address - Country:US
Practice Address - Phone:573-893-7848
Practice Address - Fax:573-893-1984
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SD2742207Q00000X
MN48304207Q00000X
MOR9F28207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5300890Medicaid
SD5300890Medicaid
SD100055Medicare ID - Type Unspecified