Provider Demographics
NPI:1174738793
Name:TAYLOR, MARK ALLEN (IDC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALLEN
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5905 34TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55450-2900
Mailing Address - Country:US
Mailing Address - Phone:612-713-4849
Mailing Address - Fax:612-713-4644
Practice Address - Street 1:5905 34TH AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55450-2900
Practice Address - Country:US
Practice Address - Phone:612-713-4849
Practice Address - Fax:612-713-4644
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman