Provider Demographics
NPI:1528703998
Name:BEATTY, PARKER (DO)
Entity type:Individual
Prefix:
First Name:PARKER
Middle Name:
Last Name:BEATTY
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:I MARINE EXPEDITIONARY FORCE
Mailing Address - Street 2:200 MERCY CIRCLE RD (RM 4172)
Mailing Address - City:CAMP PENDLETON
Mailing Address - State:CA
Mailing Address - Zip Code:92055
Mailing Address - Country:US
Mailing Address - Phone:760-719-5100
Mailing Address - Fax:
Practice Address - Street 1:MCAS MIRAMAR BRANCH HEALTH CLINIC
Practice Address - Street 2:2496 BAUER RD
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126
Practice Address - Country:US
Practice Address - Phone:858-307-9907
Practice Address - Fax:619-696-9259
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-30
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102208059208D00000X
171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171000000XOther Service ProvidersMilitary Health Care ProviderGroup - Single Specialty
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty