Provider Demographics
NPI:1528043494
Name:PAUL W BEAVER OD PC
Entity Type:Organization
Organization Name:PAUL W BEAVER OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:W
Authorized Official - Last Name:BEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:712-722-1270
Mailing Address - Street 1:105 S MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX CENTER
Mailing Address - State:IA
Mailing Address - Zip Code:51250-1535
Mailing Address - Country:US
Mailing Address - Phone:712-722-1270
Mailing Address - Fax:712-722-1282
Practice Address - Street 1:105 S MAIN AVE
Practice Address - Street 2:
Practice Address - City:SIOUX CENTER
Practice Address - State:IA
Practice Address - Zip Code:51250-1535
Practice Address - Country:US
Practice Address - Phone:712-722-1270
Practice Address - Fax:712-722-1282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1885152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0282442Medicaid
IA28244OtherBLUE CROSS
IA28244OtherBLUE CROSS
IA0458590001Medicare NSC