Provider Demographics
NPI:1306907803
Name:BEAVERSON, JANICE MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:JANICE
Middle Name:MARIE
Last Name:BEAVERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2101 EAST JEFFERSON STREET
Mailing Address - Street 2:PPQA MEDICARE COMPLIANCE UNIT 6W ATTN THERESA JACKSON
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:301-816-6308
Practice Address - Street 1:2101 EAST JEFFERSON STREET
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-4908
Practice Address - Country:US
Practice Address - Phone:301-816-6425
Practice Address - Fax:301-816-7115
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101034431207Q00000X
MDD0028076207Q00000X
DCMDO38336207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B94409Medicare UPIN
198407M92Medicare ID - Type Unspecified