Healthcare Provider Details

I. General information

NPI: 1700867983
Provider Name (Legal Business Name): JEREMY WADE TAYLOR O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 02/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2207 PORTLAND RD STE A
NEWBERG OR
97132-1371
US

IV. Provider business mailing address

2207 PORTLAND RD STE A
NEWBERG OR
97132-1371
US

V. Phone/Fax

Practice location:
  • Phone: 503-538-3277
  • Fax:
Mailing address:
  • Phone: 503-538-3277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3201ATI
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: