MEDICARE: GUY RANDALL BEAVERS OD

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	3914TG	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00308V	OTHER	TX	MEDICARE GROUP PTAN

General Provider Information

NPI Number	:	1144279092
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GUY RANDALL BEAVERS OD

Provider Business Mailing Address
First Line	:	4314 W. BRAKER LN
Second Line	:	SUITE 215
City	:	SPRING
State	:	TX
Zip	:	78757-0000
Country	:	US
Telephone Number	:	512-327-4123
Fax Number	:	512-327-9156

Provider Business Practice Location Address
First Line	:	4314 W. BRAKER LN
Second Line	:	SUITE 215
City	:	SPRING
State	:	TX
Zip	:	78757-0000
Country	:	US
Telephone Number	:	512-327-4123
Fax Number	:	512-327-9156

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

Provider Enumeration Date	:	05/09/2006
Last Update Date	:	09/12/2013

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