Provider Demographics
NPI:1144200387
Name:MEYERS, LARRY J (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:J
Last Name:MEYERS
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 1:2100 HIGHWAY 61 N
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-8211
Mailing Address - Country:US
Mailing Address - Phone:601-883-5000
Mailing Address - Fax:
Practice Address - Street 1:2100 HIGHWAY 61 N
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-8211
Practice Address - Country:US
Practice Address - Phone:601-883-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-21
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-6923367H00000X
MS19387207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5M969OtherBCBS
AR111182001Medicaid
MS09851064Medicaid
AR5M696Medicare ID - Type Unspecified
MS09851064Medicaid
AR111182001Medicaid