Provider Demographics
NPI:1801086368
Name:THEUNISSEN, TAYLOR BRYAN (MD)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:BRYAN
Last Name:THEUNISSEN
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 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-526-0006
Mailing Address - Fax:225-765-9291
Practice Address - Street 1:5233 DIJON DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4692
Practice Address - Country:US
Practice Address - Phone:225-218-6108
Practice Address - Fax:225-223-6010
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA026454207X00000X, 2082S0099X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1063444Medicaid
MS05285897Medicaid
LA1063444Medicaid