Provider Demographics
NPI:1083739346
Name:TAYLOR, ANTONIA K (OD)
Entity Type:Individual
Prefix:
First Name:ANTONIA
Middle Name:K
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 WATSON BLVD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31028-1245
Mailing Address - Country:US
Mailing Address - Phone:478-953-7168
Mailing Address - Fax:
Practice Address - Street 1:2930 WATSON BLVD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:GA
Practice Address - Zip Code:31028-1245
Practice Address - Country:US
Practice Address - Phone:478-953-7168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1725152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist