Provider Demographics
NPI:1114972221
Name:OFFICER, TODD M (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:M
Last Name:OFFICER
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:PO BOX 1450 # NW7813
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55485-0001
Mailing Address - Country:US
Mailing Address - Phone:218-732-2800
Mailing Address - Fax:218-732-2874
Practice Address - Street 1:705 PLEASANT AVE S
Practice Address - Street 2:
Practice Address - City:PARK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56470-1440
Practice Address - Country:US
Practice Address - Phone:218-732-2800
Practice Address - Fax:218-732-2874
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDRL-0437207Q00000X
MN52316207Q00000X
MNTP-104372207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5612802Medicaid
SD5612803Medicaid
SD4992652OtherWELLMARK
SDP00463249OtherRR MEDICARE
SD492921OtherWELLMARK
SD5612800Medicaid
SD7038OtherDAKOTACARE
SD4994117OtherWELLMARK
SD7038OtherDAKOTACARE
SDS101980Medicare PIN
SD4994117OtherWELLMARK
SD5612800Medicaid