Basic Information
| Provider Information | |||||||||
| NPI: | 1801086368 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | THEUNISSEN | ||||||||
| FirstName: | TAYLOR | ||||||||
| MiddleName: | BRYAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5959 S SHERWOOD FOREST BLVD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708166038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2255260006 | ||||||||
| FaxNumber: | 2257659291 | ||||||||
| Practice Location | |||||||||
| Address1: | 5233 DIJON DR | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708084692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252186108 | ||||||||
| FaxNumber: | 2252236010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2007 | ||||||||
| LastUpdateDate: | 04/28/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 026454 | LA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 2082S0099X | 026454 | LA | N | Allopathic & Osteopathic Physicians | Plastic Surgery | Plastic Surgery Within the Head and Neck | 2086S0122X | 026454 | LA | Y | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1063444 | 05 | LA | MEDICAID | 05285897 | 05 | MS | MEDICAID |