Healthcare Provider Details

I. General information

NPI: 1114543287
Provider Name (Legal Business Name): TODD R WALDORF DO PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

555 BREED HILL ROAD
CROWN POINT NY
12928-1731
US

IV. Provider business mailing address

555 BREED HILL ROAD
CROWN POINT NY
12928-1731
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. TODD ROBERT WALDORF
Title or Position: OWNER / PHYSICIAN
Credential: D.O.
Phone: 518-526-9996