Provider Demographics
NPI:1871661355
Name:TAYLOR, JOHN E (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
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 1:403 S DELAWARE ST
Mailing Address - Street 2:
Mailing Address - City:CONRAD
Mailing Address - State:MT
Mailing Address - Zip Code:59425-2310
Mailing Address - Country:US
Mailing Address - Phone:406-278-5331
Mailing Address - Fax:406-278-7379
Practice Address - Street 1:403 S DELAWARE ST
Practice Address - Street 2:
Practice Address - City:CONRAD
Practice Address - State:MT
Practice Address - Zip Code:59425-2310
Practice Address - Country:US
Practice Address - Phone:406-278-5331
Practice Address - Fax:406-278-7379
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMT345152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT048-9684Medicaid
MT81-0333388OtherMT EIN #
MTT89237Medicare UPIN
MT048-9684Medicaid