Provider Demographics
NPI:1558583716
Name:BEVAN, RICHARD SCOTT (DPM)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:SCOTT
Last Name:BEVAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:R
Other - Middle Name:SCOTT
Other - Last Name:BEVAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:P O BOX 171258
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-1258
Mailing Address - Country:US
Mailing Address - Phone:801-243-3801
Mailing Address - Fax:307-886-5652
Practice Address - Street 1:998 COUNTY ROAD 148
Practice Address - Street 2:
Practice Address - City:SMOOT
Practice Address - State:WY
Practice Address - Zip Code:83126
Practice Address - Country:US
Practice Address - Phone:801-243-3801
Practice Address - Fax:307-886-5652
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT92213E00000X
WY58213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTT89130Medicare UPIN
WY307288Medicare ID - Type Unspecified