Provider Demographics
NPI:1164547709
Name:BEALE, MARK D I (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:BEALE
Suffix:I
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:133 WYATT DR
Mailing Address - Street 2:SUITE 9
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-2962
Mailing Address - Country:US
Mailing Address - Phone:575-680-2684
Mailing Address - Fax:575-680-2655
Practice Address - Street 1:133 WYATT DR
Practice Address - Street 2:SUITE 9
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-2962
Practice Address - Country:US
Practice Address - Phone:575-680-2684
Practice Address - Fax:575-680-2655
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM93-2082084P2900X, 208VP0000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1164547709Medicaid
NM1164547709OtherPSYCHIATRY/PAIN MANAGEMENT