Provider Demographics
NPI:1124780887
Name:BYRD, AUDREY (DO)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:BYRD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2345 SOUTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74107-2705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2345 SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74107-2705
Practice Address - Country:US
Practice Address - Phone:918-960-4146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-11
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OK8602208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty