Provider Demographics
NPI:1962430835
Name:TAYLOR, BRUCE KENNETH (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:KENNETH
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:ATTN: CREDENTIALING/PAYER ENROLLMENT
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2528 SISTER MARY COLUMBA DR
Practice Address - Street 2:
Practice Address - City:RED BLUFF
Practice Address - State:CA
Practice Address - Zip Code:96080-4327
Practice Address - Country:US
Practice Address - Phone:530-528-6100
Practice Address - Fax:530-528-6146
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30395207X00000X
ORMD168405207X00000X
CAC50150207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01303957Medicaid
COC22531Medicare UPIN
CO01303957Medicaid