MEDICARE: BEVERLY ANN WIATREK O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2472TG	TX

General Provider Information

NPI Number	:	1083678353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BEVERLY ANN WIATREK O.D.

Provider Business Mailing Address
First Line	:	3310 E SOUTHCROSS BLVD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78223-1922
Country	:	US
Telephone Number	:	210-534-8863
Fax Number	:	210-534-8551

Provider Business Practice Location Address
First Line	:	3310 E SOUTHCROSS BLVD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78223-1922
Country	:	US
Telephone Number	:	210-534-8863
Fax Number	:	210-534-8551

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2006
Last Update Date	:	12/02/2013

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