Provider Demographics
NPI:1952448532
Name:PRIDDY, MYRA D (MD)
Entity Type:Individual
Prefix:DR
First Name:MYRA
Middle Name:D
Last Name:PRIDDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:127 HIDDEN VALLEY ESTS
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-9300
Mailing Address - Country:US
Mailing Address - Phone:304-253-9355
Mailing Address - Fax:304-253-0018
Practice Address - Street 1:315 FAIRVIEW HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-1086
Practice Address - Country:US
Practice Address - Phone:304-872-5213
Practice Address - Fax:304-872-5893
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2016-12-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WV19575207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV20150000Medicaid
WV20150000Medicaid
WVPR4080736Medicare PIN