Healthcare Provider Details

I. General information

NPI: 1770148306
Provider Name (Legal Business Name): MARK DOUGLAS BYRD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2019
Last Update Date: 05/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 16TH ST NE
WASHINGTON DC
20002-2555
US

IV. Provider business mailing address

1260 16TH ST NE
WASHINGTON DC
20002-2555
US

V. Phone/Fax

Practice location:
  • Phone: 202-826-2324
  • Fax:
Mailing address:
  • Phone: 202-826-2324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: