Provider Demographics
NPI:1861460354
Name:TAYLOR, DONALD KENWOOD (OD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:KENWOOD
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 1:332 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-4038
Mailing Address - Country:US
Mailing Address - Phone:304-325-8685
Mailing Address - Fax:304-324-0429
Practice Address - Street 1:332 NORTH ST
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-4038
Practice Address - Country:US
Practice Address - Phone:304-325-8685
Practice Address - Fax:304-324-0429
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV689-OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001719832OtherMT STATE BCBS
VA009204342Medicaid
WV0150605000Medicaid
VA0452014OtherANTHEM BC BS
VA0452015OtherANTHEM BC BS
VA037848OtherBCBS
VA0452015OtherANTHEM BC BS
WV408540374AMedicare PIN
WV001719832OtherMT STATE BCBS
VA009204342Medicaid
WV9297102Medicare PIN
WV9171462Medicare PIN
WV0202110001Medicare NSC
VA0452014OtherANTHEM BC BS
WVT32566Medicare UPIN