Provider Demographics
NPI:1740285931
Name:BEAVER, JASON D (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:D
Last Name:BEAVER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2800 ROSS CLARK CIR STE 2
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-9917
Mailing Address - Country:US
Mailing Address - Phone:334-305-1848
Mailing Address - Fax:334-305-1849
Practice Address - Street 1:2800 ROSS CLARK CIR STE 2
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-9917
Practice Address - Country:US
Practice Address - Phone:334-305-1848
Practice Address - Fax:334-305-1849
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21102208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051518010OtherAL BCBS # FOR OFFICE #1
AL051518009OtherAL BCBS # FOR OFFICE #2
AL009936495Medicaid
AL131066Medicaid
AL102I020491Medicare PIN
AL051518009OtherAL BCBS # FOR OFFICE #2
AL051518009Medicare ID - Type UnspecifiedAL MEDICARE # OFFICE #2
G57767Medicare UPIN