Provider Demographics
NPI:1770862815
Name:BYRD, TAEKWONDO JONOHN (MD)
Entity Type:Individual
Prefix:
First Name:TAEKWONDO
Middle Name:JONOHN
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:PO BOX 911057
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-1057
Mailing Address - Country:US
Mailing Address - Phone:303-643-1099
Mailing Address - Fax:303-643-1176
Practice Address - Street 1:11600 W 2ND PL
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-1527
Practice Address - Country:US
Practice Address - Phone:720-321-0000
Practice Address - Fax:720-321-1759
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0053368207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO59433752Medicaid
COP01373713OtherRAIL ROAD MEDICARE
COP01373713OtherRAIL ROAD MEDICARE
CO352217YJTEMedicare PIN
CO352217YLTTMedicare PIN
CO352217YL2GMedicare PIN