Provider Demographics
NPI:1487815130
Name:TODD, JACQUELINE ELAINE (D O)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:ELAINE
Last Name:TODD
Suffix:
Gender:F
Credentials:D O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 2ND AVE SW
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-3120
Mailing Address - Country:US
Mailing Address - Phone:727-584-7706
Mailing Address - Fax:727-585-8542
Practice Address - Street 1:1301 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-3120
Practice Address - Country:US
Practice Address - Phone:727-584-7706
Practice Address - Fax:727-585-8542
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10054207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL326295OtherAVMED
FL62658OtherBCBS
FL001972800Medicaid
FL1093619OtherCAREPLUS
FL9385165OtherAETNA
FL1444743OtherCIGNA