Provider Demographics
NPI:1154404556
Name:BEAVER, WALTER (MD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:
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 1:18077 RIVER AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46062-8311
Mailing Address - Country:US
Mailing Address - Phone:317-674-0208
Mailing Address - Fax:317-674-0210
Practice Address - Street 1:18077 RIVER AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46062-8311
Practice Address - Country:US
Practice Address - Phone:317-674-0208
Practice Address - Fax:317-674-0210
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01025309207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100125340Medicaid
080158166Medicare PIN
IN100125340Medicaid
INC24817Medicare UPIN