Healthcare Provider Details

I. General information

NPI: 1174928311
Provider Name (Legal Business Name): KEITH E. TAYLOR, O.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2014
Last Update Date: 10/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 ATLANTIC AVE
MARBLEHEAD MA
01945-2911
US

IV. Provider business mailing address

166 ATLANTIC AVE
MARBLEHEAD MA
01945-2911
US

V. Phone/Fax

Practice location:
  • Phone: 781-631-2182
  • Fax:
Mailing address:
  • Phone: 781-631-2182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. KEITH TAYLOR
Title or Position: OWNER
Credential: O.D.
Phone: 781-631-2182