Provider Demographics
NPI:1346654498
Name:BEAUCHAMP, JOHNATHAN LOWELL (OD)
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:LOWELL
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 1:240 W COOK RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44907-2451
Mailing Address - Country:US
Mailing Address - Phone:419-525-3737
Mailing Address - Fax:419-525-3740
Practice Address - Street 1:240 W COOK RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-2451
Practice Address - Country:US
Practice Address - Phone:419-525-3737
Practice Address - Fax:419-525-3740
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1952DT152W00000X
OH6265152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist