Provider Demographics
NPI:1558155051
Name:BEAUDRIE, JOHNATHAN THOMAS (MD)
Entity type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:THOMAS
Last Name:BEAUDRIE
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 ROAD 2AC
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-8441
Mailing Address - Country:US
Mailing Address - Phone:307-899-0128
Mailing Address - Fax:
Practice Address - Street 1:1400 W 22ND ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1554
Practice Address - Country:US
Practice Address - Phone:605-357-1380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-08
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program