Provider Demographics
NPI:1144451527
Name:WALDEN, TAYLOR GRANT (OD)
Entity type:Individual
Prefix:DR
First Name:TAYLOR
Middle Name:GRANT
Last Name:WALDEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 N PERRY ST
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47346-1223
Mailing Address - Country:US
Mailing Address - Phone:765-489-4463
Mailing Address - Fax:765-489-5897
Practice Address - Street 1:50 N PERRY ST
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:IN
Practice Address - Zip Code:47346-1223
Practice Address - Country:US
Practice Address - Phone:765-489-4463
Practice Address - Fax:765-489-5897
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-03
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1572152W00000X, 152W00000X
IN18003616A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist