Provider Demographics
NPI:1174580377
Name:BEATTY, MAXINE RUTH (MD)
Entity type:Individual
Prefix:DR
First Name:MAXINE
Middle Name:RUTH
Last Name:BEATTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MAXINE
Other - Middle Name:
Other - Last Name:SPOOL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1212 LAKE JAMES DR
Mailing Address - Street 2:STE C
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464
Mailing Address - Country:US
Mailing Address - Phone:757-523-4589
Mailing Address - Fax:757-523-8920
Practice Address - Street 1:1212 LAKE JAMES DR
Practice Address - Street 2:STE C
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464
Practice Address - Country:US
Practice Address - Phone:757-523-4589
Practice Address - Fax:757-523-8920
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101025142208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010107580Medicaid
VA010107580Medicaid