Healthcare Provider Details

I. General information

NPI: 1376838045
Provider Name (Legal Business Name): ANGELA JADE BEAVERS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2011
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 DODGE ST
OMAHA NE
68114-4113
US

IV. Provider business mailing address

1509 N 129TH AVENUE CIR
OMAHA NE
68154-1072
US

V. Phone/Fax

Practice location:
  • Phone: 402-250-9233
  • Fax:
Mailing address:
  • Phone: 402-250-9233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number6650
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number28901
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateSD
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberQ7531
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: