Provider Demographics
NPI:1073932828
Name:BYRD, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BYRD
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 1:5429 COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:GRACEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32440-1858
Mailing Address - Country:US
Mailing Address - Phone:850-263-0639
Mailing Address - Fax:
Practice Address - Street 1:5429 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:GRACEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32440-1858
Practice Address - Country:US
Practice Address - Phone:850-263-0639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME129136207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program