Provider Demographics
NPI:1699734806
Name:TAYLOR, JON Q
Entity type:Individual
Prefix:
First Name:JON
Middle Name:Q
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 161
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51102-0161
Mailing Address - Country:US
Mailing Address - Phone:308-647-4900
Mailing Address - Fax:308-647-5378
Practice Address - Street 1:801 5TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51101-1394
Practice Address - Country:US
Practice Address - Phone:308-647-4900
Practice Address - Fax:308-647-5378
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA213192085R0202X
NE128922085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7796252Medicaid
IA1081638Medicaid
IAI0174Medicare ID - Type Unspecified
E58202Medicare UPIN