Provider Demographics
NPI:1700148962
Name:TAYLOR, JENNIFER (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-1328
Mailing Address - Country:US
Mailing Address - Phone:203-732-1256
Mailing Address - Fax:
Practice Address - Street 1:130 DIVISION ST
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418-1326
Practice Address - Country:US
Practice Address - Phone:203-732-1257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA304193207RC0000X
390200000X
CT54461207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02673751Medicaid
LA2435264Medicaid
LA2435264Medicaid