Provider Demographics
NPI:1427251099
Name:BEWERSDORF, MARYBETH (MD)
Entity type:Individual
Prefix:
First Name:MARYBETH
Middle Name:
Last Name:BEWERSDORF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 HOLLAND STE 101
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-2568
Mailing Address - Country:US
Mailing Address - Phone:949-588-2190
Mailing Address - Fax:949-588-2199
Practice Address - Street 1:5 HOLLAND STE 101
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-2568
Practice Address - Country:US
Practice Address - Phone:949-588-2190
Practice Address - Fax:949-588-2199
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64584207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG64584Medicare ID - Type Unspecified
CAB21250Medicare UPIN