Provider Demographics
NPI:1225198013
Name:BEATTY, JEREMY A (OD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:A
Last Name:BEATTY
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 1:224 S WOODS MILL RD
Mailing Address - Street 2:SUITE 700 SOUTH
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3451
Mailing Address - Country:US
Mailing Address - Phone:314-469-1230
Mailing Address - Fax:314-469-6709
Practice Address - Street 1:224 S WOODS MILL RD
Practice Address - Street 2:SUITE 700 SOUTH
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3451
Practice Address - Country:US
Practice Address - Phone:314-469-1230
Practice Address - Fax:314-469-6709
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004019126152W00000X
IL046009701152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO195289OtherBLUE CROSS BLUE SHIELD
IL046009701Medicaid
MO319173803Medicaid
MOV01532Medicare UPIN
ILP00349851Medicare PIN
MO195289OtherBLUE CROSS BLUE SHIELD
MOP00163710Medicare PIN
ILK11325Medicare PIN
MO319173803Medicaid
MO256864278Medicare PIN