Provider Demographics
NPI:1174928311
Name:KEITH E. TAYLOR, O.D.
Entity type:Organization
Organization Name:KEITH E. TAYLOR, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:781-631-2182
Mailing Address - Street 1:166 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:MARBLEHEAD
Mailing Address - State:MA
Mailing Address - Zip Code:01945-2911
Mailing Address - Country:US
Mailing Address - Phone:781-631-2182
Mailing Address - Fax:
Practice Address - Street 1:166 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:MARBLEHEAD
Practice Address - State:MA
Practice Address - Zip Code:01945-2911
Practice Address - Country:US
Practice Address - Phone:781-631-2182
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-30
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0348988Medicaid
MA192258Medicare PIN
MA0348988Medicaid
MA0273090001Medicare NSC