Provider Demographics
NPI:1710087424
Name:BYRD, CHARLES LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:LEE
Last Name:BYRD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 FAIRMONT WAY
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-3584
Mailing Address - Country:US
Mailing Address - Phone:954-384-4799
Mailing Address - Fax:
Practice Address - Street 1:1625 SE 3RD AVE
Practice Address - Street 2:SUITE 610
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2521
Practice Address - Country:US
Practice Address - Phone:954-763-5705
Practice Address - Fax:954-763-2702
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME157182086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD65657Medicare UPIN
FL91607Medicare ID - Type UnspecifiedINDIVIDUAL