Provider Demographics
NPI:1871595082
Name:BEAVERS, CLARENCE HENRY (MD)
Entity type:Individual
Prefix:
First Name:CLARENCE
Middle Name:HENRY
Last Name:BEAVERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1693
Mailing Address - Street 2:
Mailing Address - City:BRYSON CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28713-1693
Mailing Address - Country:US
Mailing Address - Phone:336-967-0004
Mailing Address - Fax:828-538-4441
Practice Address - Street 1:207 E MEADOW RD STE 1
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-3469
Practice Address - Country:US
Practice Address - Phone:336-627-3194
Practice Address - Fax:336-627-3208
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC39543207Q00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00935587OtherRAILROAD MEDICARE
NC2154554DOtherMEDICARE PTAN
NC1871595082Medicaid