Provider Demographics
NPI:1780697987
Name:TAYLOR, EARL
Entity type:Individual
Prefix:DR
First Name:EARL
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2075 EDGEWATER COURT
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-3862
Mailing Address - Country:US
Mailing Address - Phone:209-466-0678
Mailing Address - Fax:209-466-6544
Practice Address - Street 1:2075 EDGEWATER COURT
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-3862
Practice Address - Country:US
Practice Address - Phone:209-466-0678
Practice Address - Fax:209-466-6544
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC24898208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C248980Medicare PIN