Provider Demographics
NPI:1669486692
Name:BEVARD, BRENT D (DO)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:D
Last Name:BEVARD
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-261-1600
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:1 LINCOLN PKWY STE 300
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3261
Practice Address - Country:US
Practice Address - Phone:601-261-1600
Practice Address - Fax:601-268-5819
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-1167-01208100000X
MS18004208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03184271Medicaid
H40396Medicare UPIN
MS406186YKFFMedicare PIN