Healthcare Provider Details

I. General information

NPI: 1194795906
Provider Name (Legal Business Name): HENRY J TAYLOR III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 10/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3010 STATE ROUTE 109
COPALIS BEACH WA
98535-0339
US

IV. Provider business mailing address

PO BOX 34703
SEATLE WA
98124-1703
US

V. Phone/Fax

Practice location:
  • Phone: 360-289-2427
  • Fax: 360-289-9982
Mailing address:
  • Phone: 206-764-3335
  • Fax: 206-764-0489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35-065592
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: