Provider Demographics
NPI:1851399505
Name:MYERS, JERRY K (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:K
Last Name:MYERS
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 1:5500 KELL BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76310-1612
Mailing Address - Country:US
Mailing Address - Phone:940-696-5335
Mailing Address - Fax:940-696-1114
Practice Address - Street 1:5500 KELL BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76310-1612
Practice Address - Country:US
Practice Address - Phone:940-696-5335
Practice Address - Fax:940-696-1114
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2013-12-19
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
TXE2757208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110622103Medicaid
TX81720XOtherBCBS
TX081928184OtherMEDICARE RAILROAD
TX81720XOtherBCBS