Provider Demographics
NPI:1356447510
Name:BEEBE, MARISA (OD)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:BEEBE
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 1:11103 WEST AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213
Mailing Address - Country:US
Mailing Address - Phone:210-524-6803
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:1445 W. SOUTHERN AVENUE
Practice Address - Street 2:SPACE 2192
Practice Address - City:MEZA
Practice Address - State:AZ
Practice Address - Zip Code:85202
Practice Address - Country:US
Practice Address - Phone:480-345-9913
Practice Address - Fax:480-345-8709
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1527152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V10691Medicare UPIN
111948Medicare PIN