MEDICARE: JOHNATHAN LOWELL BEAUCHAMP 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	1952DT	KY
2	152W00000X	Optometrist	6265	OH

General Provider Information

NPI Number	:	1346654498
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHNATHAN LOWELL BEAUCHAMP O.D.

Provider Business Mailing Address
First Line	:	240 W COOK RD
Second Line	:
City	:	MANSFIELD
State	:	OH
Zip	:	44907-2451
Country	:	US
Telephone Number	:	419-525-3737
Fax Number	:	419-525-3740

Provider Business Practice Location Address
First Line	:	240 W COOK RD
Second Line	:
City	:	MANSFIELD
State	:	OH
Zip	:	44907-2451
Country	:	US
Telephone Number	:	419-525-3737
Fax Number	:	419-525-3740

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

Provider Enumeration Date	:	06/17/2014
Last Update Date	:	06/26/2015

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