Provider Demographics
NPI:1790753366
Name:BEAM, JEREMY VAUGHN (OD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:VAUGHN
Last Name:BEAM
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:PO BOX 1138
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362
Mailing Address - Country:US
Mailing Address - Phone:509-529-2020
Mailing Address - Fax:509-529-2115
Practice Address - Street 1:22 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362
Practice Address - Country:US
Practice Address - Phone:509-529-2020
Practice Address - Fax:509-529-2115
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3912152W00000X
OR2979T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0323400001OtherMC SUPPLY CIGNA DMERC
8886644808OtherCOMMUNITY HEALTH PLAN WA
7666593OtherAETNA
610605300OtherDEPT OF LABOR SEATTLE DFE
022886006OtherREGENCE OREGON
910940489OtherCOMERCIAL CLAIMS
0190335OtherDEPT OF LABOR & INDUSTRY
WA2029635Medicaid
2576OtherGROUP HEALTH
5485BEOtherREGENCE WASHINGTON
P00251501OtherTRAVELERS MEDICARE RETIRE
0323400001OtherMC SUPPLY CIGNA DMERC
V04858Medicare UPIN