Provider Demographics
NPI:1063486397
Name:MYERS, KEVIN SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:SCOTT
Last Name:MYERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 N 25TH ST
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081
Mailing Address - Country:US
Mailing Address - Phone:920-457-9100
Mailing Address - Fax:920-457-1461
Practice Address - Street 1:1440 N 25TH ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081
Practice Address - Country:US
Practice Address - Phone:920-457-9100
Practice Address - Fax:920-457-1461
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24584207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI391497952OtherFEDERAL TAX ID
WIB55290Medicare UPIN