Provider Demographics
NPI:1508856402
Name:TODD, DOUGLAS EUGENE (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:EUGENE
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 1:3156 VISTA WAY
Mailing Address - Street 2:SUITE 405
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-3622
Mailing Address - Country:US
Mailing Address - Phone:760-439-6581
Mailing Address - Fax:760-439-6585
Practice Address - Street 1:28062 BAXTER RD
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-1401
Practice Address - Country:US
Practice Address - Phone:951-290-4112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG066549174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G665490Medicaid
CA00G665490Medicaid
CAE93649Medicare UPIN