Healthcare Provider Details

I. General information

NPI: 1295767812
Provider Name (Legal Business Name): JEFFREY R TAYLOR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 10/20/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 W. BAKER STREET STE 103
COSTA MESA CA
92626
US

IV. Provider business mailing address

PO BOX 2405
SUISUN CITY CA
94585-5405
US

V. Phone/Fax

Practice location:
  • Phone: 714-668-2525
  • Fax: 714-668-2530
Mailing address:
  • Phone: 657-241-3600
  • Fax: 657-241-7708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA70382
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberA70382
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: