Provider Demographics
NPI:1780675611
Name:BEASLEY, CLIFTON H JR (MD)
Entity type:Individual
Prefix:
First Name:CLIFTON
Middle Name:H
Last Name:BEASLEY
Suffix:JR
Gender:M
Credentials:MD
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 650037
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0037
Mailing Address - Country:US
Mailing Address - Phone:214-696-2008
Mailing Address - Fax:
Practice Address - Street 1:900 W MAGNOLIA AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-8517
Practice Address - Country:US
Practice Address - Phone:817-334-0882
Practice Address - Fax:817-334-0885
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE3851207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00781819OtherRAILROAD MEDICARE
TX48795103Medicaid
TX48795102Medicaid
TX8L21214Medicare PIN
TXP00781819OtherRAILROAD MEDICARE
TX8L21203Medicare PIN