Provider Demographics
NPI:1043207020
Name:TAYLOR, TAVIS J (MD)
Entity Type:Individual
Prefix:
First Name:TAVIS
Middle Name:J
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 1:3036 PERRY AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-5349
Mailing Address - Country:US
Mailing Address - Phone:360-627-8493
Mailing Address - Fax:360-627-7920
Practice Address - Street 1:3036 PERRY AVE
Practice Address - Street 2:SUITE A
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-5349
Practice Address - Country:US
Practice Address - Phone:360-627-8493
Practice Address - Fax:360-627-7920
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00030507207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA128813OtherLABOR & INDUSTRIES
WA263080490OtherKPS HEALTHPLANS
WA8241556Medicaid
WA91114366509OtherKPS HEALTHPLANS
WA91114366598310A009OtherTRICARE
WATA7118OtherREGENCE
WAAB08657Medicare ID - Type Unspecified
WAG8897409Medicare PIN
WATA7118OtherREGENCE