Provider Demographics
NPI:1518212778
Name:STODDARD, CHRISTOPHER ALAN (DPT, OTR/L)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:ALAN
Last Name:STODDARD
Suffix:
Gender:M
Credentials:DPT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31200 N RED FIR RD
Mailing Address - Street 2:
Mailing Address - City:ATHOL
Mailing Address - State:ID
Mailing Address - Zip Code:83801-3100
Mailing Address - Country:US
Mailing Address - Phone:208-818-7404
Mailing Address - Fax:208-567-9508
Practice Address - Street 1:610 HUBBARD AVE STE 226
Practice Address - Street 2:
Practice Address - City:COEUR D'ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-818-7404
Practice Address - Fax:208-567-9508
Is Sole Proprietor?:No
Enumeration Date:2012-07-13
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60316402225100000X
IDOT-1335225X00000X
WAOT60300760225X00000X
IDPT-3666225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8911917Medicare PIN