Provider Demographics
NPI:1083631659
Name:TAYLOR, JERALD B (DO)
Entity Type:Individual
Prefix:
First Name:JERALD
Middle Name:B
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 120
Mailing Address - Street 2:
Mailing Address - City:NEPHI
Mailing Address - State:UT
Mailing Address - Zip Code:84648-0120
Mailing Address - Country:US
Mailing Address - Phone:435-623-3200
Mailing Address - Fax:435-623-3180
Practice Address - Street 1:48 W 1500 N
Practice Address - Street 2:
Practice Address - City:NEPHI
Practice Address - State:UT
Practice Address - Zip Code:84648-8900
Practice Address - Country:US
Practice Address - Phone:435-623-3200
Practice Address - Fax:435-623-3180
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT375388-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870419324004Medicaid
UT870419324004Medicaid