Healthcare Provider Details

I. General information

NPI: 1578768156
Provider Name (Legal Business Name): TODD MADISON LOPER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 TURIN TER STE 120
ST AUGUSTINE FL
32092-0849
US

IV. Provider business mailing address

PO BOX 3266
ST AUGUSTINE FL
32085-3266
US

V. Phone/Fax

Practice location:
  • Phone: 904-819-3223
  • Fax:
Mailing address:
  • Phone: 904-819-4602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number71388
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME112813
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: