Provider Demographics
NPI:1558322180
Name:MYERS, MICHAEL GLENN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GLENN
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 1:6496 DEER HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95120-1634
Mailing Address - Country:US
Mailing Address - Phone:888-318-8900
Mailing Address - Fax:
Practice Address - Street 1:6496 DEER HOLLOW DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95120-1634
Practice Address - Country:US
Practice Address - Phone:888-318-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224686-012085R0202X
CAG526312085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA93166Medicare UPIN