Provider Demographics
NPI:1508803529
Name:BEALL, BROOK DARRETT (MD)
Entity Type:Individual
Prefix:
First Name:BROOK
Middle Name:DARRETT
Last Name:BEALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9225 MIRA MESA BLVD
Mailing Address - Street 2:208
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4820
Mailing Address - Country:US
Mailing Address - Phone:858-860-5699
Mailing Address - Fax:858-860-5699
Practice Address - Street 1:5555 GROSSMONT CENTER DR
Practice Address - Street 2:GROSSMONT HOSPITAL EMERGENCY DEPARTMENT
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3019
Practice Address - Country:US
Practice Address - Phone:619-740-3958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA96186207P00000X
MA219688207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
I19086Medicare UPIN