Provider Demographics
NPI:1972056349
Name:BEAUDRY, JOHN DEREK
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DEREK
Last Name:BEAUDRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3356 E GULF TO LAKE HWY
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34453-3230
Mailing Address - Country:US
Mailing Address - Phone:352-419-7081
Mailing Address - Fax:
Practice Address - Street 1:3356 E GULF TO LAKE HWY
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34453-3230
Practice Address - Country:US
Practice Address - Phone:352-419-7081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver