Basic Information
| Provider Information | |||||||||
| NPI: | 1811316250 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEYTIN | ||||||||
| FirstName: | LEON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35 TALCOTTVILLE ROAD | ||||||||
| Address2: | SUITE 06 | ||||||||
| City: | VERNON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159558465 | ||||||||
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| Practice Location | |||||||||
| Address1: | 623 NEWFIELD AVENUE | ||||||||
| Address2: | |||||||||
| City: | STAMFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608706385 | ||||||||
| FaxNumber: | 8608700625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2014 | ||||||||
| LastUpdateDate: | 08/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 64873 | CT | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 64873 | 01 | CT | CT LIC | OTHER |