Provider Demographics
NPI:1689615692
Name:BEAVER, RODERICK WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:RODERICK
Middle Name:WILLIAM
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 1:34400 NE LESTER AVE
Mailing Address - Street 2:
Mailing Address - City:LA CENTER
Mailing Address - State:WA
Mailing Address - Zip Code:98629-3413
Mailing Address - Country:US
Mailing Address - Phone:360-448-0587
Mailing Address - Fax:360-263-4928
Practice Address - Street 1:174 1ST AVE N
Practice Address - Street 2:
Practice Address - City:ILWACO
Practice Address - State:WA
Practice Address - Zip Code:98624-9137
Practice Address - Country:US
Practice Address - Phone:360-448-0587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041270207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1016271Medicaid
WA8323198Medicaid
H60755Medicare UPIN