Provider Demographics
NPI:1790770139
Name:TAYLOR, IRA SCOTT (DO)
Entity Type:Individual
Prefix:
First Name:IRA
Middle Name:SCOTT
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 S MOUNT AUBURN RD
Mailing Address - Street 2:SUITE 418
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4911
Mailing Address - Country:US
Mailing Address - Phone:573-332-6000
Mailing Address - Fax:
Practice Address - Street 1:150 S MOUNT AUBURN RD
Practice Address - Street 2:SUITE 418
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4910
Practice Address - Country:US
Practice Address - Phone:573-332-6000
Practice Address - Fax:573-332-6125
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2002012699207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO245822705Medicaid
MO245822705Medicaid
H59982Medicare UPIN