Provider Demographics
NPI:1033121322
Name:TAYLOR, TIMOTHY OSBORN (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:OSBORN
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8893 SADDLEHORN
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-4957
Mailing Address - Country:US
Mailing Address - Phone:208-523-6750
Mailing Address - Fax:
Practice Address - Street 1:2330 CORONADO ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7407
Practice Address - Country:US
Practice Address - Phone:208-552-1234
Practice Address - Fax:208-522-9580
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2012-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5782208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDDI379OtherBLUE CROSS
UT000012701OtherCMS NORIDIAN ADM SERVICES
ID804289600Medicaid
ID0004082OtherBLUE SHIELD
IDDI379OtherBLUE CROSS
ID1137628Medicare PIN
ID1033121322Medicare UPIN