MEDICARE: BEVERLY ANN KOTARA WIATREK, 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

General Provider Information

NPI Number	:	1528089398
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEVERLY ANN KOTARA WIATREK, OD

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	:	OWNER
Name	:	BEVERLY WIATREK
Credential	:	O.D.
Telephone Number	:	210-534-8863

Provider Enumeration Date	:	07/21/2006
Last Update Date	:	08/22/2020

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