Provider Demographics
NPI:1316083215
Name:MARY C. BEAULIEU, OD
Entity type:Organization
Organization Name:MARY C. BEAULIEU, OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:C
Authorized Official - Last Name:BEAULIEU
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:860-442-5058
Mailing Address - Street 1:125 BOSTON POST RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-2812
Mailing Address - Country:US
Mailing Address - Phone:860-442-5058
Mailing Address - Fax:860-443-4118
Practice Address - Street 1:125 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-2812
Practice Address - Country:US
Practice Address - Phone:860-442-5058
Practice Address - Fax:860-443-4118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2212152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTT83603Medicare UPIN