Provider Demographics
NPI:1477311017
Name:BEASLEY, HERBERT MICHAEL JR
Entity Type:Individual
Prefix:
First Name:HERBERT
Middle Name:MICHAEL
Last Name:BEASLEY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15017 EMERALD COAST PKWY
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-3358
Mailing Address - Country:US
Mailing Address - Phone:850-650-0353
Mailing Address - Fax:
Practice Address - Street 1:15017 EMERALD COAST PKWY
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-3358
Practice Address - Country:US
Practice Address - Phone:850-650-0353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-08
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO5886156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician