Provider Demographics
NPI:1932205317
Name:MERRILL, TODD M (PT)
Entity type:Individual
Prefix:MR
First Name:TODD
Middle Name:M
Last Name:MERRILL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:MR
Other - First Name:MONTY
Other - Middle Name:
Other - Last Name:MERRILL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:631 SOUTH HAM LN.
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242
Mailing Address - Country:US
Mailing Address - Phone:209-368-7433
Mailing Address - Fax:209-368-4219
Practice Address - Street 1:631 SOUTH HAM LN.
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242
Practice Address - Country:US
Practice Address - Phone:209-368-7433
Practice Address - Fax:209-368-4219
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT12568225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT125680Medicare ID - Type UnspecifiedMEDICARE P.T. PROVIDER NU