Provider Demographics
NPI:1831442656
Name:LISTER, JEDEDIAH BEAL (OD)
Entity type:Individual
Prefix:DR
First Name:JEDEDIAH
Middle Name:BEAL
Last Name:LISTER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-5327
Mailing Address - Country:US
Mailing Address - Phone:505-325-7070
Mailing Address - Fax:505-325-5812
Practice Address - Street 1:15 S RIVER RD STE 150
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2106
Practice Address - Country:US
Practice Address - Phone:435-465-2230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-17
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NM678152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM678OtherNM STATE LICENSE