Basic Information
| Provider Information | |||||||||
| NPI: | 1952477911 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAYLOR | ||||||||
| FirstName: | W | ||||||||
| MiddleName: | LEONARD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TAYLOR | ||||||||
| OtherFirstName: | WALTER | ||||||||
| OtherMiddleName: | LEONARD | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5856 CORPORATE AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CYPRESS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906304754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7142364000 | ||||||||
| FaxNumber: | 7142364006 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 TERRACINA BLVD | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923734850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093355628 | ||||||||
| FaxNumber: | 9093356482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 06/03/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | A18137 | CA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 00A181370 | 05 | CA | MEDICAID |