Healthcare Provider Details

I. General information

NPI: 1154315877
Provider Name (Legal Business Name): MARK D BYRON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 06/27/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 S 1ST ST
JESUP GA
31545
US

IV. Provider business mailing address

825 S 1ST STREET
JESUP GA
31545
US

V. Phone/Fax

Practice location:
  • Phone: 912-427-8033
  • Fax: 912-427-7565
Mailing address:
  • Phone: 912-427-8033
  • Fax: 912-427-7565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number047579
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number47579
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: