Provider Demographics
NPI:1336292077
Name:BROTHERS TAYLOR & BEZOLD INC
Entity Type:Organization
Organization Name:BROTHERS TAYLOR & BEZOLD INC
Other - Org Name:BROTHERS BEZOLD & ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BROTHERS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:417-624-5005
Mailing Address - Street 1:2013 S JOPLIN AVE
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-2033
Mailing Address - Country:US
Mailing Address - Phone:417-624-5005
Mailing Address - Fax:417-624-5215
Practice Address - Street 1:2013 S JOPLIN AVE
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-2033
Practice Address - Country:US
Practice Address - Phone:417-624-5005
Practice Address - Fax:417-624-5215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02388152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507591907Medicaid
MO000007902Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
MO507591907Medicaid