Healthcare Provider Details

I. General information

NPI: 1700994795
Provider Name (Legal Business Name): NICOLE M TODAR DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 09/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

995 MAR WALT DR
FORT WALTON BEACH FL
32547-6758
US

IV. Provider business mailing address

PO BOX 850001 DEPT 991
ORLANDO FL
32885-0991
US

V. Phone/Fax

Practice location:
  • Phone: 850-863-7887
  • Fax: 850-863-0863
Mailing address:
  • Phone: 800-248-1639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberOS7509
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: