Provider Demographics
NPI:1639364532
Name:TEDDER, TAYLOR D (OD)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:D
Last Name:TEDDER
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 1:766 W LOS ANGELES AVE
Mailing Address - Street 2:D3
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021
Mailing Address - Country:US
Mailing Address - Phone:805-523-3440
Mailing Address - Fax:
Practice Address - Street 1:766 W LOS ANGELES AVE
Practice Address - Street 2:D3
Practice Address - City:MOORPARK
Practice Address - State:CA
Practice Address - Zip Code:93021-9302
Practice Address - Country:US
Practice Address - Phone:805-523-3440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13350T152W00000X
CA13350152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist