Provider Demographics
NPI:1982660742
Name:BEAVERS, HOMER KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:HOMER
Middle Name:KEVIN
Last Name:BEAVERS
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 1:101 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-3363
Mailing Address - Country:US
Mailing Address - Phone:479-968-2345
Mailing Address - Fax:479-890-7194
Practice Address - Street 1:101 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801
Practice Address - Country:US
Practice Address - Phone:479-968-2345
Practice Address - Fax:479-890-7194
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-6569207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR113402001Medicaid
ARD04336Medicare UPIN
AR113402001Medicaid