Provider Demographics
NPI:1710115886
Name:BEATTY, RACHAEL M (OD)
Entity Type:Individual
Prefix:
First Name:RACHAEL
Middle Name:M
Last Name:BEATTY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W KENT AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-6609
Mailing Address - Country:US
Mailing Address - Phone:406-272-0453
Mailing Address - Fax:406-221-3754
Practice Address - Street 1:1200 W KENT AVE STE 101
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-6609
Practice Address - Country:US
Practice Address - Phone:406-272-0453
Practice Address - Fax:406-221-3754
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010206152W00000X, 152WP0200X
MT816152WP0200X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046010206Medicaid
IL046010206Medicaid