Healthcare Provider Details

I. General information

NPI: 1154874212
Provider Name (Legal Business Name): JUSTIN BEITEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2016
Last Update Date: 07/21/2022
Certification Date: 11/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 E ELWOOD ST STE 500
PHOENIX AZ
85040-1978
US

IV. Provider business mailing address

4605 E ELWOOD ST STE 500
PHOENIX AZ
85040-1978
US

V. Phone/Fax

Practice location:
  • Phone: 407-985-9389
  • Fax:
Mailing address:
  • Phone: 407-985-9389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberTRN23654
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number23654
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: