Provider Demographics
NPI:1508161894
Name:BYRUM, GARY A (IDC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:BYRUM
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2008 STUMP NECK RD
Mailing Address - Street 2:NAVEODTECDIV
Mailing Address - City:INDIAN HEAD
Mailing Address - State:MD
Mailing Address - Zip Code:20640-5070
Mailing Address - Country:US
Mailing Address - Phone:757-375-2160
Mailing Address - Fax:
Practice Address - Street 1:2008 STUMP NECK RD
Practice Address - Street 2:NAVAL EXPLOSIVE ORDNANCE DISPOSAL TECHNOLOGY DIVISION
Practice Address - City:INDIAN HEAD
Practice Address - State:MD
Practice Address - Zip Code:20640-5070
Practice Address - Country:US
Practice Address - Phone:757-375-2160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman