Provider Demographics
NPI:1205813268
Name:MEYERSON, MITCHELL (MD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:
Last Name:MEYERSON
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 1:1015 ROANOKE AVE
Mailing Address - Street 2:SUITE C4
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2735
Mailing Address - Country:US
Mailing Address - Phone:631-369-3474
Mailing Address - Fax:631-369-6265
Practice Address - Street 1:1149 OLD COUNTRY RD
Practice Address - Street 2:SUITE C4
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2057
Practice Address - Country:US
Practice Address - Phone:631-369-3474
Practice Address - Fax:631-369-6265
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-29
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY183449174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG02008Medicare UPIN