Provider Demographics
NPI:1720383953
Name:BEAZLEY, WYATT SANFORD III (MD)
Entity Type:Individual
Prefix:DR
First Name:WYATT
Middle Name:SANFORD
Last Name:BEAZLEY
Suffix:III
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 1:2320 MONUMENT AVENUE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-2604
Mailing Address - Country:US
Mailing Address - Phone:804-355-1956
Mailing Address - Fax:
Practice Address - Street 1:2320 MONUMENT AVENUE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220-2604
Practice Address - Country:US
Practice Address - Phone:804-355-1956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-19
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101014880208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery