Provider Demographics
NPI:1891806162
Name:BEATY, CLISTO D (MD)
Entity Type:Individual
Prefix:
First Name:CLISTO
Middle Name:D
Last Name:BEATY
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:PO BOX 311
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:UT
Mailing Address - Zip Code:84651-0311
Mailing Address - Country:US
Mailing Address - Phone:801-423-1039
Mailing Address - Fax:
Practice Address - Street 1:1000 E 100 N
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-1600
Practice Address - Country:US
Practice Address - Phone:800-748-4868
Practice Address - Fax:801-733-5872
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT169252-1205207L00000X
IDM-4600207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT51728OtherHEALTHY U
UT107006158102OtherIHC
UT7820OtherPEHP
UT36319OtherDESERET MUTUAL
UTQM0000076595OtherALTIUS
UT870525882BE1OtherEDUCATORS MUTUAL
UTPR00524OtherMOLINA
UTC47922Medicare UPIN