Provider Demographics
NPI:1578594289
Name:TAYLOR, CHARLES L
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:L
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17868 HIGHWAY 18
Mailing Address - Street 2:SUITE # 329
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307
Mailing Address - Country:US
Mailing Address - Phone:760-946-5177
Mailing Address - Fax:
Practice Address - Street 1:17868 HIGHWAY 18
Practice Address - Street 2:SUITE # 329
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307
Practice Address - Country:US
Practice Address - Phone:760-946-5177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC386992085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C386992Medicaid
CAAO739ZMedicare PIN
CA00C386992Medicaid
CA00C386995Medicare PIN
CA00C386990Medicare PIN