1275514929 NPI number — JACQUELINE S TAYLOR ODONALD M.D.

Table of content: JACQUELINE S TAYLOR ODONALD M.D. (NPI 1275514929)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275514929 NPI number — JACQUELINE S TAYLOR ODONALD M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAYLOR ODONALD
Provider First Name:
JACQUELINE
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TAYLOR ODONALD
Provider Other First Name:
JACQUELINE
Provider Other Middle Name:
S
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1275514929
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5002 COWHORN CREEK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEXARKANA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75503-9766
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-614-3000
Provider Business Mailing Address Fax Number:
903-614-3525

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5002 COWHORN CREEK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEXARKANA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75503-9766
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-614-3000
Provider Business Practice Location Address Fax Number:
903-614-3525
Provider Enumeration Date:
11/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  L3496 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: E2888 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5M000 . This is a "BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 0092MN . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 145436001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 145871301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: DD3261 . This is a "RR MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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