Provider Demographics
NPI:1861981102
Name:VANDIVER, BEAU TAYLOR (MD)
Entity type:Individual
Prefix:
First Name:BEAU
Middle Name:TAYLOR
Last Name:VANDIVER
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 1:3894 GRANTS LN
Mailing Address - Street 2:
Mailing Address - City:IRONDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35210-5510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2700 HIGHWAY 280 S STE 300
Practice Address - Street 2:
Practice Address - City:MOUNTAIN BRK
Practice Address - State:AL
Practice Address - Zip Code:35223-2445
Practice Address - Country:US
Practice Address - Phone:205-930-9595
Practice Address - Fax:205-802-7719
Is Sole Proprietor?:No
Enumeration Date:2018-05-02
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AL390472082S0099X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program