Provider Demographics
NPI:1144279092
Name:BEAVERS, GUY RANDALL (OD)
Entity type:Individual
Prefix:
First Name:GUY
Middle Name:RANDALL
Last Name:BEAVERS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4314 W. BRAKER LN
Mailing Address - Street 2:SUITE 215
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:78757-0000
Mailing Address - Country:US
Mailing Address - Phone:512-327-4123
Mailing Address - Fax:512-327-9156
Practice Address - Street 1:4314 W. BRAKER LN
Practice Address - Street 2:SUITE 215
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:78757-0000
Practice Address - Country:US
Practice Address - Phone:512-327-4123
Practice Address - Fax:512-327-9156
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3914TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00308VOtherMEDICARE GROUP PTAN
0224150001Medicare NSC
TXT12133Medicare UPIN
TX00E70JMedicare ID - Type Unspecified