Provider Demographics
NPI:1811983091
Name:TAYLOR, DERRICK W (MD)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:W
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 929
Mailing Address - Street 2:110 NORMAN DORMINY DR SUITE B
Mailing Address - City:FITZGERALD
Mailing Address - State:GA
Mailing Address - Zip Code:31750
Mailing Address - Country:US
Mailing Address - Phone:229-423-2058
Mailing Address - Fax:229-423-0197
Practice Address - Street 1:110 NORMAN DORMINY DR
Practice Address - Street 2:SUITE B
Practice Address - City:FITZGERALD
Practice Address - State:GA
Practice Address - Zip Code:31750
Practice Address - Country:US
Practice Address - Phone:229-423-2058
Practice Address - Fax:229-423-0197
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA053043207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00339270OtherRR MEDICARE
GA11SCCQCMedicare ID - Type Unspecified
GA11SCGPRMedicare PIN
GAP00339270OtherRR MEDICARE