Provider Demographics
NPI:1801889142
Name:MYRON, STEPHEN R (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:R
Last Name:MYRON
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 1:250 N SHADELAND AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:317-962-3834
Mailing Address - Fax:
Practice Address - Street 1:430 W VOTAW ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:IN
Practice Address - Zip Code:47371-1302
Practice Address - Country:US
Practice Address - Phone:260-726-6515
Practice Address - Fax:260-726-2814
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029521A207Q00000X
IN0102951A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100348530Medicaid
IN234760EMedicare PIN
IN142560AMedicare ID - Type Unspecified
IN100348530Medicaid