Provider Demographics
NPI:1700887858
Name:VLADYKA, TODD D (DO)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:D
Last Name:VLADYKA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4190 CITY LINE AVE
Mailing Address - Street 2:SUITE 777
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-1626
Mailing Address - Country:US
Mailing Address - Phone:215-871-6910
Mailing Address - Fax:215-871-6905
Practice Address - Street 1:4190 CITY LINE AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-1626
Practice Address - Country:US
Practice Address - Phone:215-871-6380
Practice Address - Fax:215-871-6381
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS009403L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001696813Medicaid
PA001696813Medicaid
PA021208E7HMedicare ID - Type Unspecified