Provider Demographics
NPI:1861870875
Name:BEALL, BRYAN (DO)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:BEALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 N EAST AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1753
Mailing Address - Country:US
Mailing Address - Phone:517-788-4800
Mailing Address - Fax:517-817-7050
Practice Address - Street 1:2105 FOREST AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1425
Practice Address - Country:US
Practice Address - Phone:408-947-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-11
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101021970207P00000X
CA20A16731207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine