Provider Demographics
NPI:1730368341
Name:GEORGE D TAYLOR OD PC
Entity type:Organization
Organization Name:GEORGE D TAYLOR OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OD
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:D
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-426-3095
Mailing Address - Street 1:3401 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5500
Mailing Address - Country:US
Mailing Address - Phone:260-426-3095
Mailing Address - Fax:260-420-2258
Practice Address - Street 1:3401 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5500
Practice Address - Country:US
Practice Address - Phone:260-426-3095
Practice Address - Fax:260-420-2258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002045A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0313060001Medicare NSC
133590Medicare PIN