Provider Demographics
NPI:1508872722
Name:MIKURIYA, BEVERLY (MD)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:MIKURIYA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2968 STATE HIGHWAY 49
Mailing Address - Street 2:
Mailing Address - City:COOL
Mailing Address - State:CA
Mailing Address - Zip Code:95614-9477
Mailing Address - Country:US
Mailing Address - Phone:530-888-9020
Mailing Address - Fax:530-888-9030
Practice Address - Street 1:2968 STATE HIGHWAY 49 STE C
Practice Address - Street 2:
Practice Address - City:COOL
Practice Address - State:CA
Practice Address - Zip Code:95614-9478
Practice Address - Country:US
Practice Address - Phone:530-888-9020
Practice Address - Fax:530-888-9030
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27264207R00000X
PAMD065463L207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009373400001Medicaid
PA083737Medicare ID - Type Unspecified
B31948Medicare UPIN