Provider Demographics
NPI:1093829327
Name:BEAN, GARY E (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:E
Last Name:BEAN
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 1:4180 PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602
Mailing Address - Country:US
Mailing Address - Phone:510-530-5437
Mailing Address - Fax:510-530-9703
Practice Address - Street 1:4180 PARK BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602
Practice Address - Country:US
Practice Address - Phone:510-530-5437
Practice Address - Fax:510-530-9703
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53663208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG53663OtherMEDICAL