Provider Demographics
NPI:1538232293
Name:BEALL, GILDON (MD)
Entity type:Individual
Prefix:
First Name:GILDON
Middle Name:
Last Name:BEALL
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 1:1000 W CARSON ST
Mailing Address - Street 2:BOX 480
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-2004
Mailing Address - Country:US
Mailing Address - Phone:310-222-5015
Mailing Address - Fax:310-222-5027
Practice Address - Street 1:1000 W CARSON ST
Practice Address - Street 2:BOX 480
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2004
Practice Address - Country:US
Practice Address - Phone:310-222-5015
Practice Address - Fax:310-222-5027
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC21695207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C216950Medicaid
CAM050376Medicare PIN
CA00C216950Medicaid
CAWC21695CMedicare ID - Type UnspecifiedPPIN
CAA31985Medicare UPIN