Provider Demographics
NPI:1013070549
Name:TAYLOR, MARK BENJAMIN (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:BENJAMIN
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 E SEAVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-2152
Mailing Address - Country:US
Mailing Address - Phone:707-746-1397
Mailing Address - Fax:
Practice Address - Street 1:2213 BUCHANAN RD
Practice Address - Street 2:SUITE 210
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-4265
Practice Address - Country:US
Practice Address - Phone:925-779-2592
Practice Address - Fax:925-779-2521
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT16211225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist