Provider Demographics
NPI:1134108665
Name:PEABODY, TODD DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:DAVID
Last Name:PEABODY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 E ATWATER AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47405-3635
Mailing Address - Country:US
Mailing Address - Phone:812-855-8436
Mailing Address - Fax:812-855-1683
Practice Address - Street 1:800 E ATWATER AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-3635
Practice Address - Country:US
Practice Address - Phone:812-855-8436
Practice Address - Fax:812-855-1683
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003233A152W00000X
IL046.009540152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200865900Medicaid
232530JMedicare PIN
IN544150YYYMedicare PIN
IN200865900Medicaid
IN825700JJJMedicare PIN