Provider Demographics
NPI:1124207436
Name:TAYLOR, PETER JACK (DO)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:JACK
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 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10202 SE 32ND AVE STE 701
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-3625
Practice Address - Country:US
Practice Address - Phone:503-513-1410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-02
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0059712084P0800X
ORDO1542732084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500645932Medicaid