Provider Demographics
NPI:1013984681
Name:MERRIAM, STEPHEN W (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:W
Last Name:MERRIAM
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 1:5792 WIDEWATERS PKWY
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13214-1847
Mailing Address - Country:US
Mailing Address - Phone:315-422-4412
Mailing Address - Fax:315-422-4432
Practice Address - Street 1:5792 WIDEWATERS PKWY
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13214-1847
Practice Address - Country:US
Practice Address - Phone:315-422-4412
Practice Address - Fax:315-422-4432
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2019-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47874207W00000X
NY227900207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34628900Medicaid
046G15875Medicare ID - Type Unspecified
WI34628900Medicaid