Basic Information
| Provider Information | |||||||||
| NPI: | 1477540896 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAYLOR | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | KARL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4062 FLYING C RD | ||||||||
| Address2: | |||||||||
| City: | CAMERON PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956829664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306768234 | ||||||||
| FaxNumber: | 5306760819 | ||||||||
| Practice Location | |||||||||
| Address1: | 4062 FLYING C RD | ||||||||
| Address2: | |||||||||
| City: | CAMERON PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956829664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306768234 | ||||||||
| FaxNumber: | 5306760819 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 04/08/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/21/2016 | ||||||||
| NPIReactivationDate: | 04/08/2016 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | G036151 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | BT7619248 | 01 | CA | DEA | OTHER | 00G0361510 | 05 | CA | MEDICAID |