Provider Demographics
NPI:1467527028
Name:BLADH, TAYLOR WOODBURY (OD)
Entity Type:Individual
Prefix:DR
First Name:TAYLOR
Middle Name:WOODBURY
Last Name:BLADH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 N. DIAMOND BAR BLVD
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-4122
Mailing Address - Country:US
Mailing Address - Phone:909-861-3737
Mailing Address - Fax:909-396-7517
Practice Address - Street 1:718 N. DIAMOND BAR BLVD.
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-4122
Practice Address - Country:US
Practice Address - Phone:909-861-3737
Practice Address - Fax:909-396-7517
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT8921TPA152W00000X
CAOPT8921TPG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0081970Medicaid
CASD0088870Medicaid
CAFG112YMedicare PIN
CASD0088870Medicaid