Provider Demographics
NPI:1831173707
Name:TAYLOR, WALLACE EDMONDSON JR (MD)
Entity type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:EDMONDSON
Last Name:TAYLOR
Suffix:JR
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:300 BEARDSLEY LN
Mailing Address - Street 2:SUITE D-101
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-4945
Mailing Address - Country:US
Mailing Address - Phone:512-338-9840
Mailing Address - Fax:512-338-0863
Practice Address - Street 1:300 BEARDSLEY LN
Practice Address - Street 2:SUITE D-101
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-4945
Practice Address - Country:US
Practice Address - Phone:512-338-9840
Practice Address - Fax:512-338-0863
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2008-12-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CO28006207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01280064Medicaid
COP00209209OtherMEDICARE RAILROAD CARRIER
COTA37805OtherANTHEM BC/BS
COD49924Medicare UPIN
COC800474Medicare PIN