Provider Demographics
NPI:1801207543
Name:BEAVERS, MELINDA LEE
Entity Type:Individual
Prefix:DR
First Name:MELINDA
Middle Name:LEE
Last Name:BEAVERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 N BROAD STREET E
Mailing Address - Street 2:
Mailing Address - City:ANGIER
Mailing Address - State:NC
Mailing Address - Zip Code:27501-8954
Mailing Address - Country:US
Mailing Address - Phone:706-340-3138
Mailing Address - Fax:704-381-6841
Practice Address - Street 1:612 N BROAD STREET E
Practice Address - Street 2:
Practice Address - City:ANGIER
Practice Address - State:NC
Practice Address - Zip Code:27501-8954
Practice Address - Country:US
Practice Address - Phone:706-340-3138
Practice Address - Fax:704-381-6841
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-15
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2017-01520208000000X
NC201059208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1801207543Medicaid