Basic Information
Provider Information | |||||||||
NPI: | 1619973641 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TAYLOR | ||||||||
FirstName: | WAYNE | ||||||||
MiddleName: | R | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 23643 | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336233643 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7278695551 | ||||||||
FaxNumber: | 7278686488 | ||||||||
Practice Location | |||||||||
Address1: | 7525 MEDICAL DR | ||||||||
Address2: |   | ||||||||
City: | HUDSON | ||||||||
State: | FL | ||||||||
PostalCode: | 346676502 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7278695551 | ||||||||
FaxNumber: | 7278686488 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2005 | ||||||||
LastUpdateDate: | 09/03/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/01/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME0049872 | FL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 2083P0011X | ME49872 | FL | Y |   | Allopathic & Osteopathic Physicians | Preventive Medicine | Undersea and Hyperbaric Medicine |
ID Information
ID | Type | State | Issuer | Description | 010785400 | 05 | FL |   | MEDICAID | 05605 | 01 | FL | BCBS FL | OTHER |