Provider Demographics
NPI:1619015088
Name:HOSTETLER, TODD L (MD)
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:L
Last Name:HOSTETLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4147
Mailing Address - Country:US
Mailing Address - Phone:715-847-2021
Mailing Address - Fax:715-847-2325
Practice Address - Street 1:512 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4147
Practice Address - Country:US
Practice Address - Phone:715-847-2021
Practice Address - Fax:715-847-2325
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI57120-20207R00000X, 208000000X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2755102Medicaid
OH2755102Medicaid