Healthcare Provider Details

I. General information

NPI: 1417954660
Provider Name (Legal Business Name): DOUGLAS WAYNE BEAL M.D., M.S.H.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 01/05/2014
Certification Date:
Deactivation Date: 03/20/2006
Reactivation Date: 03/24/2006

III. Provider practice location address

2412 FORUM BLVD SUITE 201
COLUMBIA MO
65203-6364
US

IV. Provider business mailing address

2412 FORUM BLVD SUITE 201
COLUMBIA MO
65203-6364
US

V. Phone/Fax

Practice location:
  • Phone: 573-445-0725
  • Fax: 573-445-1027
Mailing address:
  • Phone: 573-445-0725
  • Fax: 573-445-1027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD100429
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: