Provider Demographics
NPI:1386784239
Name:MYERS, MITCHELL JEFFREY (MD)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:JEFFREY
Last Name:MYERS
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:PO BOX 23666
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3666
Mailing Address - Country:US
Mailing Address - Phone:601-200-4560
Mailing Address - Fax:601-200-4580
Practice Address - Street 1:971 LAKELAND DR STE 557
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4661
Practice Address - Country:US
Practice Address - Phone:601-200-4560
Practice Address - Fax:601-200-4580
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS102132084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0112521Medicaid
MSD00679Medicare UPIN
MS0112521Medicaid