Provider Demographics
NPI:1043270812
Name:TAYLOR, DANIEL P (O D)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:P
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 W COLISEUM BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-1010
Mailing Address - Country:US
Mailing Address - Phone:260-484-8516
Mailing Address - Fax:260-484-8521
Practice Address - Street 1:431 W COLISEUM BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805
Practice Address - Country:US
Practice Address - Phone:260-484-8516
Practice Address - Fax:260-484-8521
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002712A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200125690Medicaid
IN140210CMedicare PIN
IN669370GMedicare PIN
IN200125690Medicaid
IN669220003Medicare PIN
IN160450027Medicare PIN
IN410038863Medicare PIN
IN410046004Medicare PIN
IN410048429Medicare PIN
IN771580FMedicare PIN