Provider Demographics
NPI:1659326627
Name:MENESES, MYRNA R (MD)
Entity Type:Individual
Prefix:
First Name:MYRNA
Middle Name:R
Last Name:MENESES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 W FAIR AVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2675
Mailing Address - Country:US
Mailing Address - Phone:906-225-3936
Mailing Address - Fax:
Practice Address - Street 1:1414 W FAIR AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2675
Practice Address - Country:US
Practice Address - Phone:906-225-3936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301054887207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI102593507Medicaid
MA0305210272OtherBLUE CROSS BLUE SHIELD MI
MI102593507Medicaid
MIC61697Medicare UPIN