Provider Demographics
NPI:1821093881
Name:MEYER, JEROLD A (MD)
Entity Type:Individual
Prefix:
First Name:JEROLD
Middle Name:A
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 1:55435 TR 170
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:OH
Mailing Address - Zip Code:43824
Mailing Address - Country:US
Mailing Address - Phone:740-322-0332
Mailing Address - Fax:740-622-0335
Practice Address - Street 1:20265 EMERY RD
Practice Address - Street 2:
Practice Address - City:NORTH RANDALL
Practice Address - State:OH
Practice Address - Zip Code:44128-4122
Practice Address - Country:US
Practice Address - Phone:440-523-9966
Practice Address - Fax:216-584-2895
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35042571207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0422859Medicaid
OHC01800Medicare UPIN
OHC01800Medicare UPIN