Provider Demographics
NPI:1104824747
Name:BEAUBOEUF, PETER A (OD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:A
Last Name:BEAUBOEUF
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 1:15 WINNERS CIR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:TOPSHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04086-1740
Mailing Address - Country:US
Mailing Address - Phone:207-406-4635
Mailing Address - Fax:207-406-4627
Practice Address - Street 1:15 WINNERS CIR
Practice Address - Street 2:SUITE 2
Practice Address - City:TOPSHAM
Practice Address - State:ME
Practice Address - Zip Code:04086-1740
Practice Address - Country:US
Practice Address - Phone:207-406-4635
Practice Address - Fax:207-406-4627
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT879152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431824199Medicaid
ME 133201OtherPTAN ME
ME016356OtherANTHEM BCBS
ME016356OtherANTHEM BCBS