Healthcare Provider Details

I. General information

NPI: 1700440633
Provider Name (Legal Business Name): DR. TAYLOR BLADH O.D. INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1796 NEWPORT BLVD
COSTA MESA CA
92627-2756
US

IV. Provider business mailing address

1796 NEWPORT BLVD
COSTA MESA CA
92627-2756
US

V. Phone/Fax

Practice location:
  • Phone: 949-642-2020
  • Fax: 949-642-8753
Mailing address:
  • Phone: 949-642-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. TAYLOR WOODBURY BLADH
Title or Position: PRESIDENT
Credential: OD
Phone: 909-861-3737