Provider Demographics
NPI:1710904396
Name:BAYOUTH, JOHN MARK (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MARK
Last Name:BAYOUTH
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:PO BOX 961205
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-1205
Mailing Address - Country:US
Mailing Address - Phone:817-740-8400
Mailing Address - Fax:817-870-1602
Practice Address - Street 1:900 W MAGNOLIA AVE STE 200
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-8517
Practice Address - Country:US
Practice Address - Phone:817-882-1193
Practice Address - Fax:817-870-1602
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3553208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX030746407OtherMEDICAID CSHCN
TX030746404Medicaid
P00265372OtherRAILROAD MEDICARE
TX030746405Medicaid
TX030746408OtherMEDICAID CSHCN