=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780675611
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLIFTON H BEASLEY JR. MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2005
-----------------------------------------------------
Last Update Date | 04/11/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 W MAGNOLIA AVE SUITE 202
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-8517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-334-0882
-----------------------------------------------------
Fax | 817-334-0885
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 650037
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75265-0037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-696-2008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | E3851
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------