Provider Demographics
NPI:1104851559
Name:DEAN, BYRON RENARD (DO)
Entity Type:Individual
Prefix:DR
First Name:BYRON
Middle Name:RENARD
Last Name:DEAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3616 HARDEN BLVD
Mailing Address - Street 2:#311
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-5938
Mailing Address - Country:US
Mailing Address - Phone:863-937-7157
Mailing Address - Fax:863-333-0260
Practice Address - Street 1:1500 LAKELAND HILLS BLVD STE 4
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805
Practice Address - Country:US
Practice Address - Phone:863-937-7157
Practice Address - Fax:863-333-0260
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0S9203207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
16757OtherBLUE CROSS
FL00396100ROtherMEDICAID GROUP #
FLEY656AOtherMEDICARE GROUP PTAN
FL245345600Medicaid
FL00396100ROtherMEDICAID GROUP #
16757OtherBLUE CROSS