Provider Demographics
NPI:1063528131
Name:GEWANT, TODD MICHAEL (DC)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:MICHAEL
Last Name:GEWANT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 SANTA MONICA BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2639
Mailing Address - Country:US
Mailing Address - Phone:310-453-4100
Mailing Address - Fax:310-453-4110
Practice Address - Street 1:3200 SANTA MONICA BLVD STE 205
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2639
Practice Address - Country:US
Practice Address - Phone:310-453-4100
Practice Address - Fax:310-453-4110
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28374111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC28374Medicare ID - Type Unspecified
V07549Medicare UPIN