Provider Demographics
NPI:1700870813
Name:TAYLOR, JONATHAN B (DO)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:B
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1436 E 10TH ST STE 2
Mailing Address - Street 2:
Mailing Address - City:WINNER
Mailing Address - State:SD
Mailing Address - Zip Code:57580-2875
Mailing Address - Country:US
Mailing Address - Phone:605-202-4810
Mailing Address - Fax:605-202-4811
Practice Address - Street 1:1436 E 10TH ST STE 2
Practice Address - Street 2:
Practice Address - City:WINNER
Practice Address - State:SD
Practice Address - Zip Code:57580-2875
Practice Address - Country:US
Practice Address - Phone:605-202-4810
Practice Address - Fax:605-202-4811
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD9354207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA52018Medicaid
IA52018Medicaid
I00336Medicare UPIN