Provider Demographics
NPI:1043245574
Name:CUSTER, TODD ROBERT (DC)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:ROBERT
Last Name:CUSTER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 W MONTGOMERY ST
Mailing Address - Street 2:
Mailing Address - City:WILLIS
Mailing Address - State:TX
Mailing Address - Zip Code:77378-8830
Mailing Address - Country:US
Mailing Address - Phone:936-856-8908
Mailing Address - Fax:936-856-8022
Practice Address - Street 1:804 W MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:WILLIS
Practice Address - State:TX
Practice Address - Zip Code:77378-8830
Practice Address - Country:US
Practice Address - Phone:936-856-8908
Practice Address - Fax:936-856-8022
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10274111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX612626Medicare UPIN