Basic Information
| Provider Information | |||||||||
| NPI: | 1568494391 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEAN | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1874 SE PORT ST LUCIE BLVD | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349525545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723377676 | ||||||||
| FaxNumber: | 7723379034 | ||||||||
| Practice Location | |||||||||
| Address1: | 1874 SE PORT ST LUCIE BLVD | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349525545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723377676 | ||||||||
| FaxNumber: | 7723379034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 11/16/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | ME88553 | FL | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 25MA03325600 | NJ | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | CV896Z | 01 | FL | MEDICARE PTAN (COASTAL--MFAA) | OTHER | 1488P | 01 | FL | BCBS OF FLORIDA | OTHER |