Provider Demographics
NPI:1811911373
Name:BEAUCHAMP, MARK L (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:BEAUCHAMP
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1184 CHARMING ST
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4263
Mailing Address - Country:US
Mailing Address - Phone:505-269-8313
Mailing Address - Fax:407-264-6188
Practice Address - Street 1:1184 CHARMING ST
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4263
Practice Address - Country:US
Practice Address - Phone:505-269-8313
Practice Address - Fax:407-264-6188
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME126056207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM5951Medicaid
D67378Medicare UPIN