Provider Demographics
NPI:1891718631
Name:BEASLEY, DONNIE S (DO)
Entity Type:Individual
Prefix:
First Name:DONNIE
Middle Name:S
Last Name:BEASLEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 178
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-0178
Mailing Address - Country:US
Mailing Address - Phone:269-657-2550
Mailing Address - Fax:269-657-2285
Practice Address - Street 1:310 WHITE OAK RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:MI
Practice Address - Zip Code:49065-9705
Practice Address - Country:US
Practice Address - Phone:269-624-2031
Practice Address - Fax:269-624-2261
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010940207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114995271Medicaid
MI0H06012025Medicare PIN
F57832Medicare UPIN