Provider Demographics
NPI:1073736922
Name:TAYLOR, JEROME HENRY SR (MD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:HENRY
Last Name:TAYLOR
Suffix:SR
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 1:1307 JEFFERSON SQUARE CT
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1795
Mailing Address - Country:US
Mailing Address - Phone:404-298-9573
Mailing Address - Fax:
Practice Address - Street 1:1307 JEFFERSON SQUARE CT
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1795
Practice Address - Country:US
Practice Address - Phone:404-298-9573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025839207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD41219Medicare UPIN
GA11BDWGPMedicare ID - Type Unspecified