Provider Demographics
NPI:1699496042
Name:JEFFERSON, BYRON M
Entity type:Individual
Prefix:
First Name:BYRON
Middle Name:M
Last Name:JEFFERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3088 N RIDGE
Mailing Address - Street 2:
Mailing Address - City:CRANDALL
Mailing Address - State:TX
Mailing Address - Zip Code:75114-5132
Mailing Address - Country:US
Mailing Address - Phone:214-448-4684
Mailing Address - Fax:
Practice Address - Street 1:3088 N RIDGE
Practice Address - Street 2:
Practice Address - City:CRANDALL
Practice Address - State:TX
Practice Address - Zip Code:75114-5132
Practice Address - Country:US
Practice Address - Phone:214-448-4684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-05
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX08113743171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor