Healthcare Provider Details

I. General information

NPI: 1396776464
Provider Name (Legal Business Name): BRYCE CAMERON LORD D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 WESTERN BLVD
JACKSONVILLE NC
28546-6338
US

IV. Provider business mailing address

317 WESTERN BLVD
JACKSONVILLE NC
28546-6338
US

V. Phone/Fax

Practice location:
  • Phone: 910-577-4900
  • Fax: 910-577-4910
Mailing address:
  • Phone: 910-577-4900
  • Fax: 910-577-4910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number12419A
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number202403120
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: