Provider Demographics
NPI:1013983865
Name:TODD, KATHLEEN L (DO)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:L
Last Name:TODD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:L
Other - Last Name:TODD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:406 LAKE HOWELL ROAD
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751
Mailing Address - Country:US
Mailing Address - Phone:407-691-3960
Mailing Address - Fax:407-691-3961
Practice Address - Street 1:406 LAKE HOWELL ROAD
Practice Address - Street 2:
Practice Address - City:MAILTAND
Practice Address - State:FL
Practice Address - Zip Code:32751
Practice Address - Country:US
Practice Address - Phone:407-691-3960
Practice Address - Fax:407-691-3961
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7722207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15528OtherBCBS
E6274AMedicare ID - Type Unspecified
H49195Medicare UPIN