Provider Demographics
NPI:1518968577
Name:TAYLOR, LARRY J (OD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:J
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:P.O. BOX 696
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52601-0696
Mailing Address - Country:US
Mailing Address - Phone:319-754-5518
Mailing Address - Fax:319-754-9531
Practice Address - Street 1:3031 FLINT HILLS DR
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52601-0696
Practice Address - Country:US
Practice Address - Phone:319-754-5518
Practice Address - Fax:319-754-9531
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1580152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0011866Medicaid
IA01186OtherBCBS
T00126Medicare UPIN
IA0011866Medicaid