Provider Demographics
NPI:1386622496
Name:NORTHRUP, TOD (DO)
Entity type:Individual
Prefix:DR
First Name:TOD
Middle Name:
Last Name:NORTHRUP
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4389
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-4389
Mailing Address - Country:US
Mailing Address - Phone:904-466-1197
Mailing Address - Fax:904-823-8967
Practice Address - Street 1:475 W TOWN PL STE 106
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-3648
Practice Address - Country:US
Practice Address - Phone:904-466-1197
Practice Address - Fax:904-823-8967
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7217207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL57375ZMedicare ID - Type Unspecified
FLF38728Medicare UPIN