Provider Demographics
NPI:1356330005
Name:ENGDAHL, TODD L (MD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:L
Last Name:ENGDAHL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:TODD
Other - Middle Name:LAWRENCE
Other - Last Name:ENGDAHL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4231
Practice Address - Street 1:3333 W DEYOUNG ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5884
Practice Address - Country:US
Practice Address - Phone:618-998-7000
Practice Address - Fax:618-997-6589
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036113579207P00000X
OH036113579207P00000X
ARE-14230207P00000X
KY35101207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK20358Medicare PIN
ILG65462Medicare UPIN
ILP00241136Medicare PIN