=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972781953
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TODD C SELF, DPM, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2008
-----------------------------------------------------
Last Update Date | 09/28/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 940 SYLVA LANE STE. E,
-----------------------------------------------------
City | SONORA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-533-3996
-----------------------------------------------------
Fax | 209-533-3998
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 940 SYLVA LANE STE. E,
-----------------------------------------------------
City | SONORA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-533-3996
-----------------------------------------------------
Fax | 209-533-3998
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TODD C SELF
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 209-533-3996
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | E3690
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | E3690
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------