Provider Demographics
NPI:1548384191
Name:BEAHM, BRENT W (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:W
Last Name:BEAHM
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 1510
Mailing Address - Street 2:
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-1510
Mailing Address - Country:US
Mailing Address - Phone:805-434-4989
Mailing Address - Fax:805-434-0721
Practice Address - Street 1:1400 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-5906
Practice Address - Country:US
Practice Address - Phone:805-434-4989
Practice Address - Fax:808-434-0721
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA341292085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A341290Medicaid
CA00A341290Medicaid
CAWA34129AMedicare ID - Type Unspecified