Provider Demographics
NPI:1962601880
Name:TODD WINE MD INC
Entity type:Organization
Organization Name:TODD WINE MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-726-2180
Mailing Address - Street 1:2067 W VISTA WAY
Mailing Address - Street 2:SUITE #200
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-6033
Mailing Address - Country:US
Mailing Address - Phone:760-726-2180
Mailing Address - Fax:
Practice Address - Street 1:2067 W VISTA WAY
Practice Address - Street 2:SUITE #200
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-6031
Practice Address - Country:US
Practice Address - Phone:760-726-2180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45531174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA50078Medicare UPIN