MEDICARE: DR. MARK D BEALE I MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P2900X	Pain Medicine (Psychiatry & Neurology) Physician	93-208	NM
2	208VP0000X	Pain Medicine Physician	93-208	NM
3	2084P0800X	Psychiatry Physician	93-208	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1164547709	OTHER	NM	PSYCHIATRY/PAIN MANAGEMENT

General Provider Information

NPI Number	:	1164547709
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK D BEALE I MD

Provider Business Mailing Address
First Line	:	133 WYATT DR
Second Line	:	SUITE 9
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-2962
Country	:	US
Telephone Number	:	575-680-2684
Fax Number	:	575-680-2655

Provider Business Practice Location Address
First Line	:	133 WYATT DR
Second Line	:	SUITE 9
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-2962
Country	:	US
Telephone Number	:	575-680-2684
Fax Number	:	575-680-2655

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	02/22/2019

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Directions to “ DR. MARK D BEALE I MD” Practice Location

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