Provider Demographics
NPI:1295844199
Name:TAYLOR, DAVID DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:DOUGLAS
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 N 6TH ST # 1778
Mailing Address - Street 2:
Mailing Address - City:EMERY
Mailing Address - State:SD
Mailing Address - Zip Code:57332-2124
Mailing Address - Country:US
Mailing Address - Phone:317-432-0940
Mailing Address - Fax:
Practice Address - Street 1:200 BUNKER HILL DR
Practice Address - Street 2:
Practice Address - City:AITKIN
Practice Address - State:MN
Practice Address - Zip Code:56431-1865
Practice Address - Country:US
Practice Address - Phone:218-927-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN40821207Q00000X
WI49600207Q00000X
IA36014207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G74490Medicare UPIN