Provider Demographics
NPI:1720185788
Name:BEVAN, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:BEVAN
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 1:622 W MAPLE ST STE H
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6589
Mailing Address - Country:US
Mailing Address - Phone:505-326-6521
Mailing Address - Fax:505-325-6699
Practice Address - Street 1:812 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5631
Practice Address - Country:US
Practice Address - Phone:505-326-6521
Practice Address - Fax:505-325-6699
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM82-11207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTT0078Medicaid
NM23325Medicaid
AZ225442Medicaid
CO91082115Medicaid
CO91082115Medicaid
NMD24560Medicare UPIN
UTT0078Medicaid
390002825Medicare PIN
COC263318Medicare PIN
NM2133900Medicare PIN