Provider Demographics
NPI:1669455077
Name:TAYLOR, JOAN WYNN (M D)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:WYNN
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:M D
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 557
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29442-0557
Mailing Address - Country:US
Mailing Address - Phone:843-833-8113
Mailing Address - Fax:843-833-8108
Practice Address - Street 1:102A S MERRIMAN RD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440
Practice Address - Country:US
Practice Address - Phone:843-833-8113
Practice Address - Fax:843-833-8108
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC12593207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4112Medicaid
SC8356Medicare PIN
SCGP4112Medicaid