Provider Demographics
NPI:1639117443
Name:MYERS, MARK ROLLAND (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ROLLAND
Last Name:MYERS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 CAROLINE AVE
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-1101
Mailing Address - Country:US
Mailing Address - Phone:606-437-7587
Mailing Address - Fax:606-437-7035
Practice Address - Street 1:109 CAROLINE AVE
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-1101
Practice Address - Country:US
Practice Address - Phone:606-437-7587
Practice Address - Fax:606-437-7035
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY966DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77009660Medicaid
KY9208802Medicare PIN
KY77009660Medicaid