Healthcare Provider Details

I. General information

NPI: 1053610923
Provider Name (Legal Business Name): BYRON LAYNE STAPLETON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2011
Last Update Date: 10/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HEALTH PARK BLVD STE 5002
ST AUGUSTINE FL
32086
US

IV. Provider business mailing address

PO BOX 3266
ST AUGUSTINE FL
32085-3266
US

V. Phone/Fax

Practice location:
  • Phone: 904-819-5861
  • Fax: 904-819-5862
Mailing address:
  • Phone: 904-819-4602
  • Fax: 904-819-4426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number34.012166
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberOS16229
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: