Provider Demographics
NPI:1578635488
Name:TODD, JEFFREY D (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:D
Last Name:TODD
Suffix:
Gender:M
Credentials:PA-C
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 843857
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3857
Mailing Address - Country:US
Mailing Address - Phone:314-966-8887
Mailing Address - Fax:314-966-3869
Practice Address - Street 1:1001 S. KIRKWOOD ROAD
Practice Address - Street 2:SUITE 120
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-7250
Practice Address - Country:US
Practice Address - Phone:314-966-8887
Practice Address - Fax:314-966-3869
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009010356363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q74384Medicare UPIN
MO133870002Medicare PIN
MO4208030001Medicare NSC
IL4208030001Medicare NSC
IL215734001Medicare PIN