Provider Demographics
NPI:1912992066
Name:BEASLEY, TODD C (DO)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:C
Last Name:BEASLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1611 S UTICA AVE
Mailing Address - Street 2:STE 617
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4909
Mailing Address - Country:US
Mailing Address - Phone:918-744-3664
Mailing Address - Fax:918-748-7688
Practice Address - Street 1:1611 S UTICA AVE
Practice Address - Street 2:STE 617
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4909
Practice Address - Country:US
Practice Address - Phone:918-744-3664
Practice Address - Fax:918-748-7688
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4024207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP00298870OtherRAILROAD MEDICARE
OK200007700AMedicaid
OK7349586OtherAETNA
OK721545605-001OtherBCBS
OK249601615Medicare PIN
OK7349586OtherAETNA
OK243431403Medicare ID - Type Unspecified