Provider Demographics
NPI:1437261906
Name:SUMWALT, TODD WILLIAM (PT)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:WILLIAM
Last Name:SUMWALT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2226 S MOONEY BLVD
Mailing Address - Street 2:SUITE A7
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93277
Mailing Address - Country:US
Mailing Address - Phone:559-622-9119
Mailing Address - Fax:559-622-9422
Practice Address - Street 1:2226 S MOONEY BLVD
Practice Address - Street 2:SUITE A7
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277
Practice Address - Country:US
Practice Address - Phone:559-622-9119
Practice Address - Fax:559-622-9422
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT185850225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT185850Medicaid
CAZZZ250892Medicaid
CAZZZ250892Medicaid