Provider Demographics
NPI:1497746135
Name:TODD, LARRY D (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:TODD
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:PO BOX 11626
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98411-6626
Mailing Address - Country:US
Mailing Address - Phone:253-565-9765
Mailing Address - Fax:253-584-6544
Practice Address - Street 1:11315 BRIDGEPORT WAY SW
Practice Address - Street 2:ST CLARE HOSPITAL
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3004
Practice Address - Country:US
Practice Address - Phone:253-581-6403
Practice Address - Fax:253-584-6544
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041941207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1118728Medicaid
WA1118728Medicaid
A50709Medicare UPIN