Provider Demographics
NPI:1376562850
Name:BEVERLY, JAMES T III (OD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:T
Last Name:BEVERLY
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:635 PIO NONO AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204
Mailing Address - Country:US
Mailing Address - Phone:478-803-0001
Mailing Address - Fax:478-254-4997
Practice Address - Street 1:635 PIO NONO AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204
Practice Address - Country:US
Practice Address - Phone:478-803-0001
Practice Address - Fax:478-254-4997
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA1471152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000687981GMedicaid
GA000687981GMedicaid