Provider Demographics
NPI:1386201739
Name:TAYLOR, WESLEY LUKE (MD, MBA)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:LUKE
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 746638
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6638
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:10337 SAN JOSE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-8223
Practice Address - Country:US
Practice Address - Phone:904-260-3200
Practice Address - Fax:904-390-7506
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1908R77559207Q00000X
FLME156895207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1908R77559OtherARIZONA LICENSE NUMBER