Provider Demographics
NPI:1417954660
Name:BEAL, DOUGLAS WAYNE (MD, MSHA)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:WAYNE
Last Name:BEAL
Suffix:
Gender:M
Credentials:MD, MSHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2412 FORUM BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-6364
Mailing Address - Country:US
Mailing Address - Phone:573-445-0725
Mailing Address - Fax:573-445-1027
Practice Address - Street 1:2412 FORUM BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-6364
Practice Address - Country:US
Practice Address - Phone:573-445-0725
Practice Address - Fax:573-445-1027
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-01
Last Update Date:2014-01-05
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
MOMD100429208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203349915Medicaid
MO203349915Medicaid