Provider Demographics
NPI:1972564185
Name:BEALS, THERESA K (OD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:K
Last Name:BEALS
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:PO BOX 2238
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44871
Mailing Address - Country:US
Mailing Address - Phone:419-625-6181
Mailing Address - Fax:419-625-7493
Practice Address - Street 1:2600 HAYES AVENUE
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870
Practice Address - Country:US
Practice Address - Phone:419-625-6181
Practice Address - Fax:419-625-7493
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3780152W00000X
OHT350152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0765300Medicaid
U13419Medicare UPIN
BED632945Medicare ID - Type Unspecified