MEDICARE: DR. RODERICK BLAIR BEAZER 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	OD60530417	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OD60530417	OTHER	WA	WASHINGTON DEPARTMENT OF HEALTH

General Provider Information

NPI Number	:	1790040673
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RODERICK BLAIR BEAZER O.D.

Provider Business Mailing Address
First Line	:	9623 32ND ST SE
Second Line	:	STE D121
City	:	LAKE STEVENS
State	:	WA
Zip	:	98258-5780
Country	:	US
Telephone Number	:	717-242-1915
Fax Number	:

Provider Business Practice Location Address
First Line	:	9623 32ND ST SE STE D121
Second Line	:
City	:	LAKE STEVENS
State	:	WA
Zip	:	98258-5780
Country	:	US
Telephone Number	:	425-377-9747
Fax Number	:	425-377-8757

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

Provider Enumeration Date	:	07/07/2012
Last Update Date	:	10/28/2020

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