Provider Demographics
NPI:1609958396
Name:TAYLOR, BONNIE F (OD)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:F
Last Name:TAYLOR
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:PO BOX 457
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:TN
Mailing Address - Zip Code:38478-0457
Mailing Address - Country:US
Mailing Address - Phone:931-363-7786
Mailing Address - Fax:931-363-7794
Practice Address - Street 1:430 E COLLEGE ST
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:TN
Practice Address - Zip Code:38478-4316
Practice Address - Country:US
Practice Address - Phone:931-363-7786
Practice Address - Fax:931-363-7794
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000864152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNT61233Medicaid
TN0730320001Medicare NSC
TN3595194Medicare PIN
TNT61233Medicaid