Healthcare Provider Details

I. General information

NPI: 1770585101
Provider Name (Legal Business Name): TODD R WALDORF D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 06/24/2020
Certification Date: 06/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 MILLER DRIVE
CROWN POINT NY
12928-2539
US

IV. Provider business mailing address

17 MILLER DRIVE
CROWN POINT NY
12928-2539
US

V. Phone/Fax

Practice location:
  • Phone: 518-526-9996
  • Fax: 518-240-4172
Mailing address:
  • Phone: 518-526-9996
  • Fax: 518-240-4987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number217602
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number217602
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number217602
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number032.0117498
License Number StateVT
# 5
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number217602
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: