Provider Demographics
NPI:1043530454
Name:TAY, JOHN C (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:TAY
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 1:630 RANDY LN
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33931-4018
Mailing Address - Country:US
Mailing Address - Phone:239-463-2723
Mailing Address - Fax:
Practice Address - Street 1:630 RANDY LN
Practice Address - Street 2:
Practice Address - City:FORT MYERS BEACH
Practice Address - State:FL
Practice Address - Zip Code:33931-4018
Practice Address - Country:US
Practice Address - Phone:239-463-2723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-08
Last Update Date:2011-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036049707207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036049709Medicaid
IL036049709Medicaid