Provider Demographics
NPI:1134110851
Name:TAYLOR, TRAVIS (OD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 D ST
Mailing Address - Street 2:PO BOX 8397
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25303-3107
Mailing Address - Country:US
Mailing Address - Phone:304-744-1303
Mailing Address - Fax:304-744-1316
Practice Address - Street 1:415 D ST
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-3107
Practice Address - Country:US
Practice Address - Phone:304-744-1303
Practice Address - Fax:304-744-1316
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV949IOD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0149981000Medicaid
WV5576315OtherAETNA
WV001722600OtherMT STATE BLUE CROSS
WVU64588Medicare UPIN
WV001722600OtherMT STATE BLUE CROSS