Healthcare Provider Details

I. General information

NPI: 1750645321
Provider Name (Legal Business Name): MITCHEL LEE BEASLEY II D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2012
Last Update Date: 07/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

997 US HIGHWAY 41 BYP N SUITE 201
VENICE FL
34285-6046
US

IV. Provider business mailing address

PO BOX 863407
ORLANDO FL
32886-3407
US

V. Phone/Fax

Practice location:
  • Phone: 941-952-4220
  • Fax: 941-952-4222
Mailing address:
  • Phone: 941-917-2600
  • Fax: 941-917-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberU03112
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS12825
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: