Healthcare Provider Details

I. General information

NPI: 1205827243
Provider Name (Legal Business Name): ROGER S. TAYLOR D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 12/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 MANCHESTER AVE
FORKED RIVER NJ
08731-1359
US

IV. Provider business mailing address

59 MANCHESTER AVE
FORKED RIVER NJ
08731-1359
US

V. Phone/Fax

Practice location:
  • Phone: 609-242-0007
  • Fax: 609-247-0143
Mailing address:
  • Phone: 609-242-0007
  • Fax: 609-247-0143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number25MD00200100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: