Provider Demographics
NPI:1043354541
Name:BEAUCHAMP, JERRY (OD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:
Last Name:BEAUCHAMP
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 1:12925 SW 74TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-5356
Mailing Address - Country:US
Mailing Address - Phone:305-251-6555
Mailing Address - Fax:305-254-6336
Practice Address - Street 1:1625 NW 107TH AVE
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33172-2707
Practice Address - Country:US
Practice Address - Phone:305-470-7866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1715152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist