Provider Demographics
NPI:1255322772
Name:BEAVER, WARREN J (MD)
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:J
Last Name:BEAVER
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 1:3822 COLONIAL AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-3826
Mailing Address - Country:US
Mailing Address - Phone:814-833-5653
Mailing Address - Fax:814-838-1153
Practice Address - Street 1:1135 LAKE ST
Practice Address - Street 2:
Practice Address - City:GIRARD
Practice Address - State:PA
Practice Address - Zip Code:16417-1049
Practice Address - Country:US
Practice Address - Phone:814-774-3155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD033986-E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000480409OtherBSU
C34578Medicare UPIN
PA480409U0WMedicare ID - Type Unspecified
PAP00282810Medicare ID - Type UnspecifiedRR