Provider Demographics
NPI:1881676054
Name:TAYLOR, TERESE A (MD)
Entity Type:Individual
Prefix:DR
First Name:TERESE
Middle Name:A
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4202 DEL PRADO BLVD S
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-7166
Mailing Address - Country:US
Mailing Address - Phone:239-540-9918
Mailing Address - Fax:239-540-9192
Practice Address - Street 1:4202 DEL PRADO BLVD S
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-7166
Practice Address - Country:US
Practice Address - Phone:239-540-9918
Practice Address - Fax:239-540-9192
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2015-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92674207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000013683GOtherSTAYWELL
FL01599OtherBC/BS OF FLORIDA
FL272932600Medicaid
FL298186OtherAVMED
FL298186OtherAVMED
FL01599OtherBC/BS OF FLORIDA