Provider Demographics
NPI:1164445755
Name:BELOTT, TODD P (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:P
Last Name:BELOTT
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 1:1208 MEDICAL PLAZA CT
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-5653
Mailing Address - Country:US
Mailing Address - Phone:817-579-7562
Mailing Address - Fax:817-579-7592
Practice Address - Street 1:1208 MEDICAL PLAZA CT
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-5653
Practice Address - Country:US
Practice Address - Phone:817-579-7562
Practice Address - Fax:817-579-7592
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2146208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX366370001Medicaid
LA1555266Medicaid
LA5E527C718Medicare ID - Type Unspecified
LA1555266Medicaid
TX542036YSGHMedicare PIN