Basic Information
| Provider Information | |||||||||
| NPI: | 1760579031 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEVARD | ||||||||
| FirstName: | WARREN | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 604 SOLAREX CT | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217038678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016989260 | ||||||||
| FaxNumber: | 3016988962 | ||||||||
| Practice Location | |||||||||
| Address1: | 604 SOLAREX CT | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217038678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016989260 | ||||||||
| FaxNumber: | 3016988962 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 02/17/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 00327 | WV | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | 01248 | MD | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | SC003667L | PA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.