Provider Demographics
NPI:1124016282
Name:TODD, MICHAEL A (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:TODD
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 664
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-0664
Mailing Address - Country:US
Mailing Address - Phone:662-534-2174
Mailing Address - Fax:662-534-7188
Practice Address - Street 1:200 HWY 30 W
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652-3112
Practice Address - Country:US
Practice Address - Phone:662-534-2174
Practice Address - Fax:662-534-7188
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9667207ZP0105X
MS07937207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3812278Medicaid
010019193OtherRAILROAD MEDICARE
MS00016755Medicaid
MS00016755Medicaid
B30232Medicare UPIN
3812270Medicare PIN
TN3812278Medicaid