Provider Demographics
NPI:1497734495
Name:MYERS, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:MYERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 E MAIN ST
Mailing Address - Street 2:PO BOX 8674
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56002-8674
Mailing Address - Country:US
Mailing Address - Phone:507-625-1811
Mailing Address - Fax:
Practice Address - Street 1:1230 E MAIN ST
Practice Address - Street 2:MANKATO CLINIC @ MAIN STREET
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56002-8674
Practice Address - Country:US
Practice Address - Phone:507-625-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN458042085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN097L1MYOtherBCBS
41084933956001C202OtherCHAMPUS
MNHP37918OtherHEALTH PARTNERS
MNNA2951022862OtherPREFERRED ONE
MN1602454OtherMEDICA
MN171361OtherUCARE
MN2227442OtherAMERICAS PPO
MN996422300Medicaid
P00039431OtherRR MEDICARE
IA0568519Medicaid
MN300003077Medicare ID - Type Unspecified
MN1602454OtherMEDICA