Provider Demographics
NPI:1285855106
Name:TAYLOR, BRANDON MARK (DO)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:MARK
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 1:4740 N PENNGROVE WAY STE 210
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-7447
Mailing Address - Country:US
Mailing Address - Phone:208-514-0203
Mailing Address - Fax:
Practice Address - Street 1:4740 N PENNGROVE WAY STE 210
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-7447
Practice Address - Country:US
Practice Address - Phone:208-514-0203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO0725208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE36331415914Medicaid