Provider Demographics
NPI:1376836262
Name:TAYLOR, MINDY
Entity Type:Individual
Prefix:DR
First Name:MINDY
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5535 S WILLIAMSON BLVD
Mailing Address - Street 2:SUITE 727
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-8311
Mailing Address - Country:US
Mailing Address - Phone:386-506-8701
Mailing Address - Fax:
Practice Address - Street 1:5535 S WILLIAMSON BLVD
Practice Address - Street 2:SUITE 727
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32128-8311
Practice Address - Country:US
Practice Address - Phone:386-506-8701
Practice Address - Fax:386-265-0577
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-25
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3493213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01085890OtherRAILROAD PTAN
FL006116800Medicaid
FLGE841ZMedicare PIN
FLGE841XMedicare PIN