Provider Demographics
NPI:1275514929
Name:TAYLOR ODONALD, JACQUELINE S (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:S
Last Name:TAYLOR ODONALD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:S
Other - Last Name:TAYLOR ODONALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5002 COWHORN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-9766
Mailing Address - Country:US
Mailing Address - Phone:903-614-3000
Mailing Address - Fax:903-614-3525
Practice Address - Street 1:5002 COWHORN CREEK RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-9766
Practice Address - Country:US
Practice Address - Phone:903-614-3000
Practice Address - Fax:903-614-3525
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3496207R00000X
ARE2888207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5M000OtherBCBS
TX0092MNOtherBCBS
AR145436001Medicaid
TX145871301Medicaid
TXDD3261OtherRR MEDICARE
AR145436001Medicaid