Provider Demographics
NPI:1487766630
Name:BEACH, MARK ADAM (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ADAM
Last Name:BEACH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5526 AUBURN DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45331-9200
Mailing Address - Country:US
Mailing Address - Phone:937-548-3732
Mailing Address - Fax:
Practice Address - Street 1:1501 WAGNER AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331-2763
Practice Address - Country:US
Practice Address - Phone:937-547-9012
Practice Address - Fax:937-547-9361
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4081/T348152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2298393Medicaid
OH2298393Medicaid
BE0844362Medicare PIN