Provider Demographics
NPI:1871213462
Name:TAYLOR, MATTHEW THOMAS
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:THOMAS
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:A66 BOAT BASIN RD
Mailing Address - Street 2:
Mailing Address - City:CAMP LEJUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28542
Mailing Address - Country:US
Mailing Address - Phone:910-440-7925
Mailing Address - Fax:
Practice Address - Street 1:A66 BOAT BASIN RD
Practice Address - Street 2:
Practice Address - City:CAMP LEJUNE
Practice Address - State:NC
Practice Address - Zip Code:28542
Practice Address - Country:US
Practice Address - Phone:910-440-7925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty CorpsmanGroup - Multi-Specialty