Provider Demographics
NPI:1487041380
Name:BECKSTEAD, SAMUEL WELLING (DO)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:WELLING
Last Name:BECKSTEAD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 PROVIDENCE WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-4951
Mailing Address - Country:US
Mailing Address - Phone:082-529-6600
Mailing Address - Fax:208-529-6602
Practice Address - Street 1:2100 PROVIDENCE WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-4951
Practice Address - Country:US
Practice Address - Phone:208-529-6600
Practice Address - Fax:208-529-6602
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-20
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS020090207W00000X
IDO-1389207W00000X, 207WX0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty