Provider Demographics
NPI:1063631448
Name:BEVINS, MICHAEL BRYAN (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BRYAN
Last Name:BEVINS
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4107 SPICEWOOD SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-8660
Mailing Address - Country:US
Mailing Address - Phone:512-342-4731
Mailing Address - Fax:512-795-9053
Practice Address - Street 1:4107 SPICEWOOD SPRINGS RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8660
Practice Address - Country:US
Practice Address - Phone:512-342-4731
Practice Address - Fax:512-795-9053
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC122184207Q00000X
TXM5633207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164170601Medicaid
TX164170601Medicaid
TX458843Medicare PIN