Provider Demographics
NPI:1154315877
Name:BYRON, MARK D (MD, PC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:BYRON
Suffix:
Gender:M
Credentials:MD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31545-0101
Mailing Address - Country:US
Mailing Address - Phone:912-427-8033
Mailing Address - Fax:912-427-7565
Practice Address - Street 1:162 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-0101
Practice Address - Country:US
Practice Address - Phone:912-427-8033
Practice Address - Fax:912-427-7565
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047579174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00833599BMedicaid
GAE95715Medicare UPIN
GA34BDDHWMedicare ID - Type Unspecified