1790753366 NPI number — DR. JEREMY VAUGHN BEAM OD

Table of content: SHREYA INALA (NPI 1346000411)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790753366 NPI number — DR. JEREMY VAUGHN BEAM OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEAM
Provider First Name:
JEREMY
Provider Middle Name:
VAUGHN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790753366
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1138
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALLA WALLA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99362
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-529-2020
Provider Business Mailing Address Fax Number:
509-529-2115

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLA WALLA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-529-2020
Provider Business Practice Location Address Fax Number:
509-529-2115
Provider Enumeration Date:
03/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  3912 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: 2979T , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0323400001 . This is a "MC SUPPLY CIGNA DMERC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8886644808 . This is a "COMMUNITY HEALTH PLAN WA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7666593 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 610605300 . This is a "DEPT OF LABOR SEATTLE DFE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 022886006 . This is a "REGENCE OREGON" identifier . This identifiers is of the category "OTHER".
  • Identifier: 910940489 . This is a "COMERCIAL CLAIMS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0190335 . This is a "DEPT OF LABOR & INDUSTRY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2029635 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2576 . This is a "GROUP HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5485BE . This is a "REGENCE WASHINGTON" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00251501 . This is a "TRAVELERS MEDICARE RETIRE" identifier . This identifiers is of the category "OTHER".




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