Provider Demographics
NPI:1598741902
Name:TAYLOR, LAURENCE EDWARD (DO)
Entity Type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:EDWARD
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0000
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4501
Practice Address - Street 1:94180 2ND ST
Practice Address - Street 2:
Practice Address - City:GOLD BEACH
Practice Address - State:OR
Practice Address - Zip Code:97444-8733
Practice Address - Country:US
Practice Address - Phone:541-247-7047
Practice Address - Fax:541-247-0123
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO12821207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1407812365OtherNBMC GROUP NPI NUMBER
ORCB3544OtherRR MEDICARE GROUP NUMBER
OR227421Medicaid
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
OR080167069OtherRR MEDICARE PTAN NUMBER
OR1407812365OtherNBMC GROUP NPI NUMBER
ORE38905Medicare UPIN
ORCB3544OtherRR MEDICARE GROUP NUMBER
OR383853Medicare Oscar/Certification
ORR111724Medicare PIN