Provider Demographics
NPI:1447359187
Name:HOUTHUYSEN, TODD WILLIAM (PA)
Entity type:Individual
Prefix:MR
First Name:TODD
Middle Name:WILLIAM
Last Name:HOUTHUYSEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2734 BEAVER RUN BLVD UNIT D
Mailing Address - Street 2:
Mailing Address - City:SURFSIDE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29575-5392
Mailing Address - Country:US
Mailing Address - Phone:973-432-6936
Mailing Address - Fax:
Practice Address - Street 1:2734 BEAVER RUN BLVD UNIT D
Practice Address - Street 2:
Practice Address - City:SURFSIDE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575-5392
Practice Address - Country:US
Practice Address - Phone:843-650-1085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP021363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJQ08209Medicare UPIN