Provider Demographics
NPI:1972033827
Name:MEYERSON, DMITRY (PH D)
Entity Type:Individual
Prefix:DR
First Name:DMITRY
Middle Name:
Last Name:MEYERSON
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02889-1046
Mailing Address - Country:US
Mailing Address - Phone:401-258-3310
Mailing Address - Fax:401-340-1052
Practice Address - Street 1:177 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02889-1046
Practice Address - Country:US
Practice Address - Phone:401-329-2210
Practice Address - Fax:401-340-1052
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-14
Last Update Date:2020-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS01629103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty