Provider Demographics
NPI:1851483978
Name:MEYERS, MARK H (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:H
Last Name:MEYERS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6291 MOURNING DOVE
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-8925
Mailing Address - Country:US
Mailing Address - Phone:315-303-4811
Mailing Address - Fax:
Practice Address - Street 1:6291 MOURNING DOVE
Practice Address - Street 2:
Practice Address - City:BALDWINSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13027-8925
Practice Address - Country:US
Practice Address - Phone:315-303-4811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV-006969152W00000X
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT36492Medicare UPIN
IL767740Medicare ID - Type Unspecified