=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811911373
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK L BEAUCHAMP MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2006
-----------------------------------------------------
Last Update Date | 03/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1184 CHARMING ST
-----------------------------------------------------
City | MAITLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32751-4263
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-269-8313
-----------------------------------------------------
Fax | 407-264-6188
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1184 CHARMING ST
-----------------------------------------------------
City | MAITLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32751-4263
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-269-8313
-----------------------------------------------------
Fax | 407-264-6188
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME126056
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------