Provider Demographics
NPI:1790040673
Name:BEAZER, RODERICK BLAIR (OD)
Entity Type:Individual
Prefix:DR
First Name:RODERICK
Middle Name:BLAIR
Last Name:BEAZER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9623 32ND ST SE
Mailing Address - Street 2:STE D121
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-5780
Mailing Address - Country:US
Mailing Address - Phone:717-242-1915
Mailing Address - Fax:
Practice Address - Street 1:9623 32ND ST SE STE D121
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-5780
Practice Address - Country:US
Practice Address - Phone:425-377-9747
Practice Address - Fax:425-377-8757
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-07
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60530417152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAOD60530417OtherWASHINGTON DEPARTMENT OF HEALTH