Healthcare Provider Details

I. General information

NPI: 1871975474
Provider Name (Legal Business Name): KIMBERLY MICHELLE BEAVERS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2015
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S ORANGE AVE
ORLANDO FL
32806-2134
US

IV. Provider business mailing address

1400 S ORANGE AVE
ORLANDO FL
32806-2134
US

V. Phone/Fax

Practice location:
  • Phone: 877-876-3627
  • Fax: 321-841-3794
Mailing address:
  • Phone: 877-876-3627
  • Fax: 321-841-3794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number297339
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME128578
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: