Provider Demographics
NPI:1609698364
Name:TAYLOR, MARK JAMES
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JAMES
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-2343
Mailing Address - Country:US
Mailing Address - Phone:660-853-1080
Mailing Address - Fax:
Practice Address - Street 1:201 E THOMPSON ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-2343
Practice Address - Country:US
Practice Address - Phone:660-853-1080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-24
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty