Provider Demographics
NPI:1063762839
Name:SCHUSTER, TODD PHILIP (PA)
Entity type:Individual
Prefix:MR
First Name:TODD
Middle Name:PHILIP
Last Name:SCHUSTER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 N H ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-2991
Mailing Address - Country:US
Mailing Address - Phone:602-828-1989
Mailing Address - Fax:
Practice Address - Street 1:660 S 200 E STE 250
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-3846
Practice Address - Country:US
Practice Address - Phone:801-359-2256
Practice Address - Fax:801-364-4392
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12672975-1206207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ136406Medicare PIN