Provider Demographics
NPI:1689656209
Name:MERTEN, JOHN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:MERTEN
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 1:2145 MOUNT PLEASANT BLVD SE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-3632
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2145 MOUNT PLEASANT BLVD SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-3632
Practice Address - Country:US
Practice Address - Phone:540-427-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-044038207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1689656209Medicaid
VA080053877OtherRR MEDICARE PIN
VA1689656209Medicaid
VA015556C18Medicare PIN
VAE12236Medicare UPIN