Provider Demographics
NPI:1396833109
Name:BEAVER, BRYAN D (MD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:D
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 1:2304 KOSSUTH ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-3240
Mailing Address - Country:US
Mailing Address - Phone:765-446-9600
Mailing Address - Fax:765-446-1100
Practice Address - Street 1:2304 KOSSUTH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-3240
Practice Address - Country:US
Practice Address - Phone:765-446-9600
Practice Address - Fax:765-446-1100
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01082967A2080N0001X
GUM18122080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300031240Medicaid
MO208338905Medicaid