=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114255965
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MYERS DERMATOLOGY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2009
-----------------------------------------------------
Last Update Date | 02/10/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5701 AMBASSADOR CAFFERY PKWY
-----------------------------------------------------
City | YOUNGSVILLE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70592-5181
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-456-3323
-----------------------------------------------------
Fax | 337-456-4638
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5701 AMBASSADOR CAFFERY PKWY
-----------------------------------------------------
City | YOUNGSVILLE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70592-5181
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-456-3323
-----------------------------------------------------
Fax | 337-456-4638
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DERMATOLOGIST
-----------------------------------------------------
Name | DR. JENNIFER MARY MYERS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 337-205-1914
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | MD202110
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------