Provider Demographics
NPI:1053306639
Name:BEISWANGER, JAY CONRAD (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:CONRAD
Last Name:BEISWANGER
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 1:80 DOCTORS DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4517
Mailing Address - Country:US
Mailing Address - Phone:850-785-8557
Mailing Address - Fax:850-785-3497
Practice Address - Street 1:80 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4517
Practice Address - Country:US
Practice Address - Phone:850-785-8557
Practice Address - Fax:850-785-3497
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0076055208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254751100Medicaid
FL254751100Medicaid
G87430Medicare UPIN