Provider Demographics
NPI:1083687776
Name:BEVERLY, ROLAND SPURGEON III (MD)
Entity Type:Individual
Prefix:DR
First Name:ROLAND
Middle Name:SPURGEON
Last Name:BEVERLY
Suffix:III
Gender:M
Credentials:MD
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Mailing Address - Street 1:24541 PACIFIC PARK DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-3065
Mailing Address - Country:US
Mailing Address - Phone:949-831-3057
Mailing Address - Fax:949-831-2515
Practice Address - Street 1:24541 PACIFIC PARK DR
Practice Address - Street 2:SUITE 103
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-3065
Practice Address - Country:US
Practice Address - Phone:949-831-3057
Practice Address - Fax:949-831-2515
Is Sole Proprietor?:No
Enumeration Date:2006-02-11
Last Update Date:2017-05-10
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Provider Licenses
StateLicense IDTaxonomies
CAG65658207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE83457Medicare UPIN