Provider Demographics
NPI:1073592960
Name:MYERS, MARK E (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:MYERS
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1414
Mailing Address - Street 2:NCB-6
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55480-1414
Mailing Address - Country:US
Mailing Address - Phone:952-525-6328
Mailing Address - Fax:952-513-6880
Practice Address - Street 1:5775 WAYZATA BLVD
Practice Address - Street 2:SUITE 190
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1222
Practice Address - Country:US
Practice Address - Phone:952-525-6328
Practice Address - Fax:952-513-6880
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2007-09-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN338072085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN856303900Medicaid
MN300002477Medicare ID - Type Unspecified
MNE57279Medicare UPIN