Provider Demographics
NPI:1932198090
Name:TAYLOR, JOHN STAFFORD (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:STAFFORD
Last Name:TAYLOR
Suffix:
Gender:M
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:PO BOX 1210
Mailing Address - Street 2:
Mailing Address - City:EDENTON
Mailing Address - State:NC
Mailing Address - Zip Code:27932-1210
Mailing Address - Country:US
Mailing Address - Phone:252-482-5171
Mailing Address - Fax:252-482-5173
Practice Address - Street 1:104 MARK DR
Practice Address - Street 2:
Practice Address - City:EDENTON
Practice Address - State:NC
Practice Address - Zip Code:27932-1756
Practice Address - Country:US
Practice Address - Phone:252-482-5171
Practice Address - Fax:252-482-5173
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9601084207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8982105Medicaid
G33198Medicare UPIN
NC8982105Medicaid