Basic Information
| Provider Information | |||||||||
| NPI: | 1710208491 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BYRD | ||||||||
| FirstName: | JOHNNIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D., PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 616788 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328616788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212474960 | ||||||||
| FaxNumber: | 8339630116 | ||||||||
| Practice Location | |||||||||
| Address1: | 737 S SEMORAN BLVD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328073121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212474960 | ||||||||
| FaxNumber: | 8339630116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2010 | ||||||||
| LastUpdateDate: | 11/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 11/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME117292 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | KW560 | 01 | FL | MEDICARE | OTHER | 016698800 | 05 | FL | MEDICAID |