Provider Demographics
NPI:1467817239
Name:MEYER, GREGORY
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:MEYER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 RED BIRD CV
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-7048
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2701 T P WHITE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-2514
Practice Address - Country:US
Practice Address - Phone:501-241-0410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-22
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA19102251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR225200000XOtherPTA TAXONOMY NUMBER