Provider Demographics
NPI:1265490619
Name:TAYLOR, JARED A (OD)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:A
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 1:77 PICKETT WAY
Mailing Address - Street 2:
Mailing Address - City:SWANSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28584-8491
Mailing Address - Country:US
Mailing Address - Phone:910-326-0113
Mailing Address - Fax:
Practice Address - Street 1:409 WESTERN BLVD
Practice Address - Street 2:SUITE 700
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6528
Practice Address - Country:US
Practice Address - Phone:910-219-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1970152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89093R2Medicaid
NC2473873Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER NUMBE
NC89093R2Medicaid