Provider Demographics
NPI:1568442085
Name:MEYER, JERRY L (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:L
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 759
Mailing Address - Street 2:
Mailing Address - City:CONCORDIA
Mailing Address - State:MO
Mailing Address - Zip Code:64020-0759
Mailing Address - Country:US
Mailing Address - Phone:660-463-7966
Mailing Address - Fax:660-463-7729
Practice Address - Street 1:905 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CONCORDIA
Practice Address - State:MO
Practice Address - Zip Code:64020-8335
Practice Address - Country:US
Practice Address - Phone:660-463-7966
Practice Address - Fax:660-463-7729
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2010-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO32834207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203628706Medicaid
MO203628706Medicaid
MOC50231Medicare UPIN