Healthcare Provider Details

I. General information

NPI: 1962104133
Provider Name (Legal Business Name): TAYLOR K ANDERSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3302 VALENCIA DR STE 201
IDAHO FALLS ID
83404-7070
US

IV. Provider business mailing address

98 POPLAR ST
BLACKFOOT ID
83221-1758
US

V. Phone/Fax

Practice location:
  • Phone: 208-524-9400
  • Fax: 208-524-9401
Mailing address:
  • Phone: 208-785-4100
  • Fax: 208-782-2984

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 State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7071689
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: