Provider Demographics
NPI:1801880034
Name:TODD, MIKE E (OD)
Entity type:Individual
Prefix:DR
First Name:MIKE
Middle Name:E
Last Name:TODD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY CENTER
Mailing Address - State:KS
Mailing Address - Zip Code:67147-2153
Mailing Address - Country:US
Mailing Address - Phone:316-755-0491
Mailing Address - Fax:316-755-1206
Practice Address - Street 1:301 E MAIN ST
Practice Address - Street 2:
Practice Address - City:VALLEY CENTER
Practice Address - State:KS
Practice Address - Zip Code:67147-2153
Practice Address - Country:US
Practice Address - Phone:316-755-0491
Practice Address - Fax:316-755-1206
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1141-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100091160BMedicaid
KS100091160BMedicaid
KS017016Medicare ID - Type Unspecified