Provider Demographics
NPI:1770822454
Name:TAYLOR, GEMETRIC T (DO)
Entity Type:Individual
Prefix:MR
First Name:GEMETRIC
Middle Name:T
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1723 STATELINE RD WEST ST (E)
Mailing Address - Street 2:
Mailing Address - City:SOUTHHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671
Mailing Address - Country:US
Mailing Address - Phone:662-550-6812
Mailing Address - Fax:662-393-3344
Practice Address - Street 1:1723 STATELINE RD WEST ST (E)
Practice Address - Street 2:
Practice Address - City:SOUTHHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671
Practice Address - Country:US
Practice Address - Phone:662-550-6812
Practice Address - Fax:662-393-3344
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-31
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
156FX1800X
MS156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician