Provider Demographics
NPI:1285628206
Name:TALBOT, TODD J (DO)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:J
Last Name:TALBOT
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 1:101 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-2570
Mailing Address - Country:US
Mailing Address - Phone:920-727-4220
Mailing Address - Fax:
Practice Address - Street 1:101 MAIN ST
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2570
Practice Address - Country:US
Practice Address - Phone:920-727-4220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39390207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30093100Medicaid
WI30093100Medicaid
G99314Medicare UPIN