Provider Demographics
NPI:1508419714
Name:FICEK, TAYLOR (OD)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:FICEK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 VEND DR STE 100
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-7751
Mailing Address - Country:US
Mailing Address - Phone:402-525-2056
Mailing Address - Fax:
Practice Address - Street 1:1080 VEND DR STE 100
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7751
Practice Address - Country:US
Practice Address - Phone:402-525-2056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-17
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT003161152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist