Provider Demographics
NPI:1790955938
Name:ROGER J BEAL DPM
Entity Type:Organization
Organization Name:ROGER J BEAL DPM
Other - Org Name:ROGER J BEAL DPM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:J
Authorized Official - Last Name:BEAL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:210-614-3623
Mailing Address - Street 1:4499 MEDICAL DR
Mailing Address - Street 2:#343
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3713
Mailing Address - Country:US
Mailing Address - Phone:210-614-3623
Mailing Address - Fax:210-614-2329
Practice Address - Street 1:4499 MEDICAL DR
Practice Address - Street 2:#343
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3713
Practice Address - Country:US
Practice Address - Phone:210-614-3623
Practice Address - Fax:210-614-2329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
00JM62Medicare PIN
0422400001Medicare NSC
T12128Medicare UPIN