Provider Demographics
NPI:1528126117
Name:BEAULIEU, MARY CHRISTINE (OD)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:CHRISTINE
Last Name:BEAULIEU
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 BOSTON POST RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-2839
Mailing Address - Country:US
Mailing Address - Phone:860-442-5058
Mailing Address - Fax:860-443-4118
Practice Address - Street 1:131 BOSTON POST RD
Practice Address - Street 2:SUITE 4
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-2839
Practice Address - Country:US
Practice Address - Phone:860-442-5058
Practice Address - Fax:860-443-4118
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2212152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004092277Medicaid
CT410000785Medicare ID - Type Unspecified
CT004092277Medicaid