Provider Demographics
NPI:1518903848
Name:MYERS, EDMUND (MD)
Entity Type:Individual
Prefix:DR
First Name:EDMUND
Middle Name:
Last Name:MYERS
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 1:2408 SE 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-5334
Mailing Address - Country:US
Mailing Address - Phone:503-233-3576
Mailing Address - Fax:503-233-2589
Practice Address - Street 1:2408 SE 16TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-5334
Practice Address - Country:US
Practice Address - Phone:503-233-3576
Practice Address - Fax:503-233-2589
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR171782084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR083571Medicaid
F05800Medicare UPIN