Basic Information
| Provider Information | |||||||||
| NPI: | 1790766525 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAYLOR | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 WHITNEY AVE | ||||||||
| Address2: | SUITE 360 | ||||||||
| City: | HAMDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065183691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032814463 | ||||||||
| FaxNumber: | 2032872930 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 WHITNEY AVE | ||||||||
| Address2: | SUITE 360 | ||||||||
| City: | HAMDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065183691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032814463 | ||||||||
| FaxNumber: | 2032872930 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 05/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 029611 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 001296111 | 05 | CT | MEDICAID |