Healthcare Provider Details

I. General information

NPI: 1598741902
Provider Name (Legal Business Name): LAURENCE EDWARD TAYLOR DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 04/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94180 2ND ST
GOLD BEACH OR
97444-8733
US

IV. Provider business mailing address

1900 WOODLAND DR
COOS BAY OR
97420-0000
US

V. Phone/Fax

Practice location:
  • Phone: 541-247-7047
  • Fax: 541-247-0123
Mailing address:
  • Phone: 541-267-5151
  • Fax: 541-266-4501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO12821
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDO12821
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: