Provider Demographics
NPI:1558565838
Name:BEAVER, CLINT (MD)
Entity Type:Individual
Prefix:
First Name:CLINT
Middle Name:
Last Name:BEAVER
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 CORPORATE PARK DR
Practice Address - Street 2:SUITE 200 & 300
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-7134
Practice Address - Country:US
Practice Address - Phone:704-235-9090
Practice Address - Fax:704-235-9101
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200901244207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5915044Medicaid
NCNC4558AMedicare PIN