Provider Demographics
NPI:1093769648
Name:BEAZLEY, WILLIAM WALTON (DO)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:WALTON
Last Name:BEAZLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 CENTRAL AVE E
Mailing Address - Street 2:
Mailing Address - City:WIGGINS
Mailing Address - State:MS
Mailing Address - Zip Code:39577-9602
Mailing Address - Country:US
Mailing Address - Phone:601-928-6700
Mailing Address - Fax:601-928-6731
Practice Address - Street 1:1440 CENTRAL AVE E
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-9602
Practice Address - Country:US
Practice Address - Phone:601-928-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14984207PE0005X
LADO.14881R207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSF84242Medicare UPIN