Provider Demographics
NPI:1710053939
Name:MEYERS, JOHN RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RUSSELL
Last Name:MEYERS
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 1:128 EAST AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-5741
Mailing Address - Country:US
Mailing Address - Phone:203-857-1866
Mailing Address - Fax:203-857-1865
Practice Address - Street 1:128 EAST AVE STE 1
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851
Practice Address - Country:US
Practice Address - Phone:203-857-1866
Practice Address - Fax:203-857-1866
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT418592084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT41859OtherMEDICAL LICENSE
XM4112796OtherDEA-DATA
FM4112796OtherDEA
I48889Medicare UPIN