Provider Demographics
NPI:1003854738
Name:BEAIRD, BRENT ALAN (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:ALAN
Last Name:BEAIRD
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 1:1636 MALABAR WAY
Mailing Address - Street 2:
Mailing Address - City:BIG BEAR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92314-9213
Mailing Address - Country:US
Mailing Address - Phone:678-570-7644
Mailing Address - Fax:
Practice Address - Street 1:41870 GARSTIN DR
Practice Address - Street 2:
Practice Address - City:BIG BEAR LAKE
Practice Address - State:CA
Practice Address - Zip Code:92315-2088
Practice Address - Country:US
Practice Address - Phone:909-866-6501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA45720207P00000X
GA046540207Q00000X
CAA139605207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H00714Medicare UPIN