Provider Demographics
NPI:1700325024
Name:BEVAN, THEODORE (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:BEVAN
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:PSC 475 BOX 1
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96350-1200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 CHOME MISUMIMACHI
Practice Address - Street 2:
Practice Address - City:IWAKUNI
Practice Address - State:YAMAGUCHI
Practice Address - Zip Code:7400025
Practice Address - Country:JP
Practice Address - Phone:082-794-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-20
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101265452207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine