Provider Demographics
NPI:1306839568
Name:WALLER, TODD STEVEN (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:STEVEN
Last Name:WALLER
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 1:1700 WESTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-5608
Mailing Address - Country:US
Mailing Address - Phone:310-470-1752
Mailing Address - Fax:310-234-6604
Practice Address - Street 1:1700 WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-5608
Practice Address - Country:US
Practice Address - Phone:310-470-1752
Practice Address - Fax:310-234-6604
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35053497207Y00000X
CAG39474207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH736455OtherBUCKEYE COMMUNITY HEALTH
OHR53497OtherSUMMACARE
OH000000123641OtherUNICARE
OH0812893Medicaid
OH000000123641OtherANTHEM BLUE SHIELD
OH2160298OtherCIGNA
OH353535OtherWELLCARE
OH736455OtherBUCKEYE COMMUNITY HEALTH
E65567Medicare UPIN
OHR53497OtherSUMMACARE