Provider Demographics
NPI:1205827243
Name:TAYLOR, ROGER S (DPM)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:S
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 MANCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731-1359
Mailing Address - Country:US
Mailing Address - Phone:609-242-0007
Mailing Address - Fax:609-247-0143
Practice Address - Street 1:59 MANCHESTER AVE
Practice Address - Street 2:
Practice Address - City:FORKED RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08731-1359
Practice Address - Country:US
Practice Address - Phone:609-242-0007
Practice Address - Fax:609-247-0143
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00200100213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4837207Medicaid
U02019Medicare UPIN
NJ620446NYKMedicare PIN
NJP00294470Medicare PIN
NJ4837207Medicaid