Provider Demographics
NPI:1386797348
Name:MONROE, TODD R (DPM)
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:R
Last Name:MONROE
Suffix:
Gender:M
Credentials:DPM
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 101
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:IL
Mailing Address - Zip Code:61011-0101
Mailing Address - Country:US
Mailing Address - Phone:815-544-9058
Mailing Address - Fax:815-544-2315
Practice Address - Street 1:411 S 2ND ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4187
Practice Address - Country:US
Practice Address - Phone:605-229-3668
Practice Address - Fax:605-226-4972
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD121213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6800132Medicaid
SDS66029Medicare ID - Type Unspecified
SD6800132Medicaid