Provider Demographics
NPI:1528163888
Name:BEAN-MAYBERRY, BEVANNE A (MD)
Entity type:Individual
Prefix:DR
First Name:BEVANNE
Middle Name:A
Last Name:BEAN-MAYBERRY
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 1:14745 VALLEYHEART DR
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1601
Mailing Address - Country:US
Mailing Address - Phone:818-895-9449
Mailing Address - Fax:
Practice Address - Street 1:16111 PLUMMER ST
Practice Address - Street 2:VA GREATER LOS ANGELES - SEPULVEDA
Practice Address - City:SEPULVEDA
Practice Address - State:CA
Practice Address - Zip Code:91343-2036
Practice Address - Country:US
Practice Address - Phone:818-895-9449
Practice Address - Fax:818-895-5838
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC52366207R00000X
PAMD 068860-L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine