Provider Demographics
NPI:1275574212
Name:TODD, MARK EDWARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:TODD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:150 EAST SAMPLE ROAD
Mailing Address - Street 2:SUITE 330
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33064-3550
Mailing Address - Country:US
Mailing Address - Phone:954-784-0330
Mailing Address - Fax:954-784-9518
Practice Address - Street 1:50 EAST SAMPLE ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064-3550
Practice Address - Country:US
Practice Address - Phone:954-942-3991
Practice Address - Fax:954-941-4594
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5359103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OTH000Medicare UPIN
FL59824Medicare PIN