Provider Demographics
NPI:1679646640
Name:TAYLOR, LOWELL WAYNE (OD)
Entity Type:Individual
Prefix:DR
First Name:LOWELL
Middle Name:WAYNE
Last Name:TAYLOR
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 1:1655 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-4061
Mailing Address - Country:US
Mailing Address - Phone:662-226-0042
Mailing Address - Fax:662-226-4696
Practice Address - Street 1:1655 SUNSET DR
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-4061
Practice Address - Country:US
Practice Address - Phone:662-226-0042
Practice Address - Fax:662-226-4696
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS440152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00833873Medicaid
MS00833873Medicaid
MS00833873Medicaid
MS410000381Medicare PIN