Healthcare Provider Details

I. General information

NPI: 1205013323
Provider Name (Legal Business Name): BEAVER MEDICAL GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 09/30/2022
Certification Date: 09/30/2022
Deactivation Date: 09/10/2009
Reactivation Date: 11/09/2012

III. Provider practice location address

33758 YUCAIPA BLVD
YUCAIPA CA
92399-2243
US

IV. Provider business mailing address

PO BOX 10069
SAN BERNARDINO CA
92423-0069
US

V. Phone/Fax

Practice location:
  • Phone: 909-795-9747
  • Fax: 909-795-4663
Mailing address:
  • Phone: 909-335-4188
  • Fax: 909-796-4158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHARLES CHEN
Title or Position: CHIEF MEDICAL OFFICER
Credential: M.D.
Phone: 909-793-3311