Provider Demographics
NPI:1497748982
Name:TAYLOR, DERRALD G (OD)
Entity Type:Individual
Prefix:
First Name:DERRALD
Middle Name:G
Last Name:TAYLOR
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 1:3241 S MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-3849
Mailing Address - Country:US
Mailing Address - Phone:312-949-7259
Mailing Address - Fax:312-949-7638
Practice Address - Street 1:3241 S MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3849
Practice Address - Country:US
Practice Address - Phone:312-225-6200
Practice Address - Fax:312-949-7660
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046006305152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046006305Medicaid
ILP15679Medicare PIN
T36499Medicare UPIN