Provider Demographics
NPI:1245218189
Name:TODD, PHILLIP J (DO)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:J
Last Name:TODD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S MASSEY ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-3248
Mailing Address - Country:US
Mailing Address - Phone:315-786-0716
Mailing Address - Fax:315-786-0716
Practice Address - Street 1:11050 MOUNT BELVEDERE BLVD
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5438
Practice Address - Country:US
Practice Address - Phone:315-772-4625
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102050075207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine