Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 1001 | CT |
NPI | 1164643797 |
---|---|
Provider Name | Mr. Edward Beaudette |
First Address | Hamden, CT 06517-3721 |
Second Address | Hamden, CT 06517-3721 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/05/2007 |
Last Update Date | 30/10/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
004054029 | (05) | CT |
100001001CT02 | ANTHEM (01) | |
CT1001 | EYEMED (01) | |
CU8360 | HEALTHNET (01) |