Provider Demographics
NPI:1780767541
Name:SOARES, TODD JOSEPH (PT)
Entity type:Individual
Prefix:MR
First Name:TODD
Middle Name:JOSEPH
Last Name:SOARES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913 LOUISA CT
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-3418
Mailing Address - Country:US
Mailing Address - Phone:707-527-7339
Mailing Address - Fax:707-523-2866
Practice Address - Street 1:1400 N DUTTON AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4657
Practice Address - Country:US
Practice Address - Phone:707-523-2848
Practice Address - Fax:707-523-2866
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT9537225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR27204Medicare UPIN
CA00PT95370Medicare ID - Type Unspecified