Provider Demographics
NPI:1376624296
Name:TAYLOR, DANETTE C (DO)
Entity Type:Individual
Prefix:DR
First Name:DANETTE
Middle Name:C
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 CHERRY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4608
Mailing Address - Country:US
Mailing Address - Phone:616-685-5050
Mailing Address - Fax:
Practice Address - Street 1:220 CHERRY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4608
Practice Address - Country:US
Practice Address - Phone:616-685-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010109612084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DT010961OtherCOMMERCIAL-COMMERCIAL NUMBER
130H264490OtherBLUE CROSS-BLUE CROSS
MI496216311Medicaid
DT010961OtherCHAMPUS-CHAMPUS
F85561Medicare UPIN
0H26449094Medicare ID - Type Unspecified