Provider Demographics
NPI:1760452312
Name:BEAN, GARY OWEN (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:OWEN
Last Name:BEAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4414 LAKE BOONE TRAIL
Mailing Address - Street 2:SUITE 502
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-7514
Mailing Address - Country:US
Mailing Address - Phone:919-875-0539
Mailing Address - Fax:919-875-1051
Practice Address - Street 1:4414 LAKE BOONE TRAIL
Practice Address - Street 2:SUITE 502
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7514
Practice Address - Country:US
Practice Address - Phone:919-875-0539
Practice Address - Fax:919-875-1051
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC23998207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8914130Medicaid
NC204686DMedicare ID - Type Unspecified
NC8914130Medicaid