Provider Demographics
NPI:1023098589
Name:TAYLOR, GEORGE D (OD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:D
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 1:3401 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5500
Mailing Address - Country:US
Mailing Address - Phone:260-426-3095
Mailing Address - Fax:260-420-2258
Practice Address - Street 1:3401 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5500
Practice Address - Country:US
Practice Address - Phone:260-426-3095
Practice Address - Fax:260-420-2258
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002045A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0313060001Medicare NSC
T83586Medicare UPIN