Provider Demographics
NPI:1609881036
Name:BEAUCHAMP, BRUCE W (DO)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:W
Last Name:BEAUCHAMP
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2521 DELORES LN
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-1524
Mailing Address - Country:US
Mailing Address - Phone:541-751-1434
Mailing Address - Fax:
Practice Address - Street 1:4021 S 700 E
Practice Address - Street 2:SUITE 220
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-2192
Practice Address - Country:US
Practice Address - Phone:800-211-4971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16476207L00000X
WA1260207L00000X
ND10096207L00000X
AK5697207L00000X
AZ3891207L00000X
ID0.198207L00000X
WV1499207L00000X
MODO 116462207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND28761OtherND BLUE CROSS BLUE SHIELD
MN1417978057OtherDEPT OF HUMAN SERVICES
NDA06171050226OtherPREFERRED ONE
ND14198Medicaid
ND20-03471OtherMEDICA