Provider Demographics
NPI:1063500403
Name:FIFE, TODD A (MD)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:A
Last Name:FIFE
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 1:2405 SE 17TH ST STE 201
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-9190
Mailing Address - Country:US
Mailing Address - Phone:352-690-2171
Mailing Address - Fax:352-690-6954
Practice Address - Street 1:4225 NW AMERICAN LN
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-8841
Practice Address - Country:US
Practice Address - Phone:386-758-6141
Practice Address - Fax:386-758-6140
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9485207Q00000X
FLME131605207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND12094Medicaid
ND12094Medicaid
H95052Medicare UPIN