Basic Information
| Provider Information | |||||||||
| NPI: | 1194715888 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEATY | ||||||||
| FirstName: | JEFFORY | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 94670 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731434670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056823303 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 700 E MARSHALL AVE | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756015580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033152000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2005 | ||||||||
| LastUpdateDate: | 07/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | K2415 | TX | N | Allopathic & Osteopathic Physicians | General Practice | 207P00000X | K2415 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 104584101 | 05 | TX | MEDICAID | 85X883 | 01 | TX | BLUE CROSS | OTHER |