Provider Demographics
NPI:1447203203
Name:BEASLEY, DARRYL K (MD)
Entity Type:Individual
Prefix:DR
First Name:DARRYL
Middle Name:K
Last Name:BEASLEY
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:PO BOX 1742
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46634-1742
Mailing Address - Country:US
Mailing Address - Phone:574-233-3123
Mailing Address - Fax:574-233-3125
Practice Address - Street 1:5215 HOLY CROSS PARKWAY
Practice Address - Street 2:ANESTHESIA DEPARTMENT
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46645
Practice Address - Country:US
Practice Address - Phone:574-335-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01047397A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200222900Medicaid
IN200222900Medicaid
G43800Medicare UPIN