Provider Demographics
NPI:1497960736
Name:BEASLEY, GENIA GAIL (OD)
Entity Type:Individual
Prefix:DR
First Name:GENIA
Middle Name:GAIL
Last Name:BEASLEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:6917 SHANNON WILLOW ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226
Mailing Address - Country:US
Mailing Address - Phone:704-405-1222
Mailing Address - Fax:704-405-1225
Practice Address - Street 1:6917 SHANNON WILLOW ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226
Practice Address - Country:US
Practice Address - Phone:704-405-1222
Practice Address - Fax:704-405-1225
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC1612152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1612OtherOPTOMETRY STATE LICENSE
NCU68757Medicare UPIN