Provider Demographics
NPI:1033392824
Name:BEAVER, PAUL W (OD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:W
Last Name:BEAVER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 S MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX CENTER
Mailing Address - State:IA
Mailing Address - Zip Code:51250-1535
Mailing Address - Country:US
Mailing Address - Phone:712-722-1270
Mailing Address - Fax:712-722-1282
Practice Address - Street 1:105 S MAIN AVE
Practice Address - Street 2:
Practice Address - City:SIOUX CENTER
Practice Address - State:IA
Practice Address - Zip Code:51250-1535
Practice Address - Country:US
Practice Address - Phone:712-722-1270
Practice Address - Fax:712-722-1282
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-14
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1885152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA28244OtherBLUE CROSS
IA0282442Medicaid
IA28244OtherBLUE CROSS
IA28244Medicare PIN