Provider Demographics
NPI:1285668426
Name:SOMMER, TODD CLARK (DO)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:CLARK
Last Name:SOMMER
Suffix:
Gender:M
Credentials:DO
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 19070
Mailing Address - Street 2:PREVEA HEALTH
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-9070
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:920-496-4749
Practice Address - Street 1:218 OLD MOCKSVILLE RD
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-1930
Practice Address - Country:US
Practice Address - Phone:704-838-7461
Practice Address - Fax:704-838-7467
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40925207Q00000X
WI612213E00000X
NC2021-00393207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30092500Medicaid
G54185Medicare UPIN
WI30092500Medicaid