Provider Demographics
NPI:1518039213
Name:MEYER, THEODORE MARK (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:MARK
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:PO BOX 2845
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29802-2845
Mailing Address - Country:US
Mailing Address - Phone:803-642-5050
Mailing Address - Fax:803-642-3369
Practice Address - Street 1:410 UNIVERSITY PKWY
Practice Address - Street 2:SUITE 2400
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801
Practice Address - Country:US
Practice Address - Phone:803-642-5050
Practice Address - Fax:803-642-3369
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7852207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC110048687OtherRAILROAD MEDICARE
SCO78524Medicaid
D992573498Medicare ID - Type Unspecified
SCO78524Medicaid