Provider Demographics
NPI:1558346403
Name:BEVILACQUA, JOANN (DPM)
Entity type:Individual
Prefix:DR
First Name:JOANN
Middle Name:
Last Name:BEVILACQUA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARNEGIE
Mailing Address - State:PA
Mailing Address - Zip Code:15106-2048
Mailing Address - Country:US
Mailing Address - Phone:412-279-3557
Mailing Address - Fax:412-279-4357
Practice Address - Street 1:411 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CARNEGIE
Practice Address - State:PA
Practice Address - Zip Code:15106-2048
Practice Address - Country:US
Practice Address - Phone:412-279-3557
Practice Address - Fax:412-279-4357
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC-000653L213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00504099Medicaid
PA00504099Medicaid
PAT27500Medicare UPIN