Healthcare Provider Details

I. General information

NPI: 1972781953
Provider Name (Legal Business Name): TODD C SELF, DPM, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2008
Last Update Date: 09/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 SYLVA LANE STE. E,
SONORA CA
95370
US

IV. Provider business mailing address

940 SYLVA LANE STE. E,
SONORA CA
95370
US

V. Phone/Fax

Practice location:
  • Phone: 209-533-3996
  • Fax: 209-533-3998
Mailing address:
  • Phone: 209-533-3996
  • Fax: 209-533-3998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberE3690
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE3690
License Number StateCA

VIII. Authorized Official

Name: TODD C SELF
Title or Position: OWNER
Credential: DPM
Phone: 209-533-3996