Provider Demographics
NPI:1134171986
Name:TODD, JEFFREY JAMES (RT(R))
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JAMES
Last Name:TODD
Suffix:
Gender:M
Credentials:RT(R)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1665
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93406-1665
Mailing Address - Country:US
Mailing Address - Phone:805-541-3174
Mailing Address - Fax:805-541-6427
Practice Address - Street 1:3170 FLORA ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-6051
Practice Address - Country:US
Practice Address - Phone:805-541-3174
Practice Address - Fax:805-541-6427
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2012-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARHT 455862471C3402X
CAFAC00029014335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
No2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA630000525OtherPALMETTO GBA
CAZZZ59902ZMedicaid
GA630000525OtherPALMETTO GBA