Provider Demographics
NPI:1720576366
Name:BEALL, STEPHEN A (LDO)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:A
Last Name:BEALL
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 N ASHLEY ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1709
Mailing Address - Country:US
Mailing Address - Phone:229-247-8484
Mailing Address - Fax:
Practice Address - Street 1:3001 N ASHLEY ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1709
Practice Address - Country:US
Practice Address - Phone:229-247-8484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO000598156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1366429599OtherCORPORATION NPI