Provider Demographics
NPI:1093709651
Name:MEYER, JACK R (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:R
Last Name:MEYER
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 1:200 PATRIOT DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE CHUTE
Mailing Address - State:WI
Mailing Address - Zip Code:54140-1184
Mailing Address - Country:US
Mailing Address - Phone:920-687-2800
Mailing Address - Fax:
Practice Address - Street 1:200 PATRIOT DR
Practice Address - Street 2:
Practice Address - City:LITTLE CHUTE
Practice Address - State:WI
Practice Address - Zip Code:54140-1184
Practice Address - Country:US
Practice Address - Phone:920-687-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27277207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30756500Medicaid
WI004145300Medicare PIN
B55059Medicare UPIN