Provider Demographics
NPI:1083678353
Name:WIATREK, BEVERLY ANN (OD)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:ANN
Last Name:WIATREK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3310 E SOUTHCROSS BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78223-1922
Mailing Address - Country:US
Mailing Address - Phone:210-534-8863
Mailing Address - Fax:210-534-8551
Practice Address - Street 1:3310 E SOUTHCROSS BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78223-1922
Practice Address - Country:US
Practice Address - Phone:210-534-8863
Practice Address - Fax:210-534-8551
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2472TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT16611Medicare UPIN
TX00E47EMedicare PIN