Provider Demographics
NPI:1609186139
Name:BYRD, JERAMY (IDMT)
Entity Type:Individual
Prefix:
First Name:JERAMY
Middle Name:
Last Name:BYRD
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9410 VERMONT CT APT A
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-9286
Mailing Address - Country:US
Mailing Address - Phone:202-360-9536
Mailing Address - Fax:
Practice Address - Street 1:9410 A VERMONT COURT
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:202-360-9536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-18
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians