Provider Demographics
NPI:1083145775
Name:PHELPS, TAYLOR SHAUN (MD)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:SHAUN
Last Name:PHELPS
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 1:650 W 42ND ST APT 1527
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-4371
Mailing Address - Country:US
Mailing Address - Phone:478-919-5420
Mailing Address - Fax:
Practice Address - Street 1:665 DULUTH HWY
Practice Address - Street 2:SUITE 401
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3328
Practice Address - Country:US
Practice Address - Phone:678-312-4077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-23
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY309854207W00000X, 207WX0009X
LA333840207W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program