Provider Demographics
NPI:1831696962
Name:LACKEY, TAYLOR GILLILAND (MD)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:GILLILAND
Last Name:LACKEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3705 MEDICAL PKWY
Mailing Address - Street 2:STE 320
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1023
Mailing Address - Country:US
Mailing Address - Phone:512-454-1873
Mailing Address - Fax:512-371-7098
Practice Address - Street 1:3705 MEDICAL PKWY STE 320
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1023
Practice Address - Country:US
Practice Address - Phone:512-454-1873
Practice Address - Fax:512-371-7098
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-05
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXV0788208600000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO136430Medicaid