Provider Demographics
NPI:1780651406
Name:TAYLOR, KEITH E (OD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:E
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 1:166 ATLANTIC AVENUE
Mailing Address - Street 2:
Mailing Address - City:MARBLEHEAD
Mailing Address - State:MA
Mailing Address - Zip Code:01945
Mailing Address - Country:US
Mailing Address - Phone:781-631-2182
Mailing Address - Fax:781-631-2142
Practice Address - Street 1:166 ATLANTIC AVENUE
Practice Address - Street 2:
Practice Address - City:MARBLEHEAD
Practice Address - State:MA
Practice Address - Zip Code:01945
Practice Address - Country:US
Practice Address - Phone:781-631-2182
Practice Address - Fax:781-631-2142
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA2954152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0348988Medicaid
MA192258Medicare PIN
MAT59289Medicare UPIN
MA0273090001Medicare NSC
MA0273090001Medicare NSC