Provider Demographics
NPI:1336140482
Name:BEASLEY, WILLIAM THOMAS (DPM)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:THOMAS
Last Name:BEASLEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4602 SOUTHERN PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40214-1442
Mailing Address - Country:US
Mailing Address - Phone:502-366-1479
Mailing Address - Fax:502-366-6718
Practice Address - Street 1:4602 SOUTHERN PKWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40214-1442
Practice Address - Country:US
Practice Address - Phone:502-366-1479
Practice Address - Fax:502-366-6718
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY126213E00000X
IN07000339A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1054679OtherPASSPORT
IN100075860Medicaid
KY90125568Medicaid
KY80001266Medicaid
KY0509801Medicare PIN
KY90125568Medicaid
KY480031630Medicare PIN
IN100075860Medicaid