Healthcare Provider Details

I. General information

NPI: 1629465752
Provider Name (Legal Business Name): MICHAEL TAYLOR D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2015
Last Update Date: 09/11/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 LAKELAND HILLS BLVD
LAKELAND FL
33805-4543
US

IV. Provider business mailing address

1324 LAKELAND HILLS BLVD ATTN: MANAGED CARE DEPT
LAKELAND FL
33805
US

V. Phone/Fax

Practice location:
  • Phone: 863-687-1259
  • Fax: 863-284-1736
Mailing address:
  • Phone: 863-687-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number285382
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberOS17637
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: