Basic Information
| Provider Information | |||||||||
| NPI: | 1578881470 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEAVER | ||||||||
| FirstName: | CODY | ||||||||
| MiddleName: | RYAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3601 4TH ST | ||||||||
| Address2: | MAIL STOP 9436 | ||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794309436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067434263 | ||||||||
| FaxNumber: | 8067431394 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 4TH ST | ||||||||
| Address2: | MAIL STOP 9436 | ||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067434263 | ||||||||
| FaxNumber: | 8067431394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2010 | ||||||||
| LastUpdateDate: | 11/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | R3034 | TX | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | BP2-0041888 | TX | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 208600000X | BP1 0036956 | TX | N | Allopathic & Osteopathic Physicians | Surgery | 207XP3100X | R3034 | TX | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 374222303 | 05 | TX | MEDICAID | 374222304 | 05 | TX | MEDICAID | 85270521 | 05 | NM | MEDICAID | 200771630A | 05 | OK | MEDICAID |