Healthcare Provider Details

I. General information

NPI: 1366414492
Provider Name (Legal Business Name): TODD MARTIN VANWYNGARDEN D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 02/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8901 W 74TH ST SUITE 200
SHAWNEE MISSION KS
66204-2204
US

IV. Provider business mailing address

8901 W 74TH ST SUITE 200
SHAWNEE MISSION KS
66204-2204
US

V. Phone/Fax

Practice location:
  • Phone: 913-432-5052
  • Fax: 913-432-9990
Mailing address:
  • Phone: 913-432-5052
  • Fax: 913-432-9990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number00245
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: