Provider Demographics
NPI:1184611170
Name:BEAVER, WAYNE LEE (MD)
Entity type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:LEE
Last Name:BEAVER
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 1:777 W STATE ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43222-1536
Mailing Address - Country:US
Mailing Address - Phone:614-221-2299
Mailing Address - Fax:614-221-7458
Practice Address - Street 1:777 W STATE ST
Practice Address - Street 2:SUITE 302
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43222-1536
Practice Address - Country:US
Practice Address - Phone:614-221-2299
Practice Address - Fax:614-221-7458
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35043307207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000216704OtherANTHEM BCBS
OH0429530Medicaid
C03673Medicare UPIN
OH0429530Medicaid