Provider Demographics
NPI:1881855708
Name:TAYLOR, TRAVIS JOHNATHAN (OD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:JOHNATHAN
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 1:2859 EAGLE EYE AVE NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-4366
Mailing Address - Country:US
Mailing Address - Phone:503-949-5050
Mailing Address - Fax:
Practice Address - Street 1:3400 STATE ST STE G770
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-7014
Practice Address - Country:US
Practice Address - Phone:503-585-6700
Practice Address - Fax:503-585-3315
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-23
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3452ATI332H00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No332H00000XSuppliersEyewear Supplier