Provider Demographics
NPI:1659533677
Name:ROLAND S. BEVERLY III, M.D., P.C.
Entity Type:Organization
Organization Name:ROLAND S. BEVERLY III, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:SPURGEON
Authorized Official - Last Name:BEVERLY
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:949-831-3057
Mailing Address - Street 1:24541 PACIFIC PARK DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-3065
Mailing Address - Country:US
Mailing Address - Phone:949-831-3057
Mailing Address - Fax:949-831-2515
Practice Address - Street 1:24541 PACIFIC PARK DR
Practice Address - Street 2:SUITE 103
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-3065
Practice Address - Country:US
Practice Address - Phone:949-831-3057
Practice Address - Fax:949-831-2515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-01
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG65658207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG65658Medicare PIN