Basic Information
| Provider Information | |||||||||
| NPI: | 1578511218 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEAMER | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3439 NE SANDY BLVD | ||||||||
| Address2: | PMB 375 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972321959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032848841 | ||||||||
| FaxNumber: | 5032823302 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 S SAINT FRANCIS DR | ||||||||
| Address2: | STE C | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875012458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054664701 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 02/28/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | MD2005-0497 | NM | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | G63150 | CA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 031018 | 05 | OR | MEDICAID |