Provider Demographics
NPI:1295705010
Name:BEACH, GREGG J (OD)
Entity type:Individual
Prefix:DR
First Name:GREGG
Middle Name:J
Last Name:BEACH
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 1:1104 PEAR TREE LN
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-6446
Mailing Address - Country:US
Mailing Address - Phone:707-252-5380
Mailing Address - Fax:707-252-5384
Practice Address - Street 1:1104 PEAR TREE LN
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-6446
Practice Address - Country:US
Practice Address - Phone:707-252-5380
Practice Address - Fax:707-252-5384
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6165152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2560OtherMES
CA089485OtherHEALTHNET
CASD0061650Medicaid
CAZZZ543922OtherBLUESHIELD
CA2560OtherMES
CAT10251Medicare UPIN
CA1117570001Medicare NSC