Healthcare Provider Details

I. General information

NPI: 1316175128
Provider Name (Legal Business Name): BRENT ROBERT TAYLOR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1541 RIVERSIDE AVE
JACKSONVILLE FL
32204-4124
US

IV. Provider business mailing address

3180 N POINT PKWY STE 420
ALPHARETTA GA
30005-4568
US

V. Phone/Fax

Practice location:
  • Phone: 866-400-3376
  • Fax:
Mailing address:
  • Phone: 407-875-2080
  • Fax: 407-650-3455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number32031
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number73661
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberA124812
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number73661
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME120226
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: