Provider Demographics
NPI:1871569889
Name:SELF, TODD C (DPM)
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:C
Last Name:SELF
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 SYLVA LN STE E
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-5969
Mailing Address - Country:US
Mailing Address - Phone:209-533-3996
Mailing Address - Fax:209-533-3998
Practice Address - Street 1:940 SYLVA LN STE E
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5969
Practice Address - Country:US
Practice Address - Phone:209-533-3996
Practice Address - Fax:209-533-3998
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3690213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E36900Medicaid
CA000E36900Medicaid
CA000E36900Medicaid
CABS2043913OtherDEA
CA0746920001Medicare NSC