Provider Demographics
NPI:1437312980
Name:BEAZLIE-WALKER, SALLY (DO)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:
Last Name:BEAZLIE-WALKER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:SALLY
Other - Middle Name:
Other - Last Name:BEAZLIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:707 CEDAR ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2057
Mailing Address - Country:US
Mailing Address - Phone:574-335-8707
Mailing Address - Fax:574-335-0741
Practice Address - Street 1:209 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-1861
Practice Address - Country:US
Practice Address - Phone:574-948-5100
Practice Address - Fax:574-348-0745
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-04
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02005023A207Q00000X
VA0102202713207Q00000X
CA20A12453207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN187720067OtherMEDICARE PTAN
INP01887772OtherRR PTAN
IN000001109741OtherBCBS
IN300004357Medicaid