Provider Demographics
NPI:1093047524
Name:BEAUZILE, THEVENIN CARL HENRY (MD)
Entity Type:Individual
Prefix:
First Name:THEVENIN
Middle Name:CARL HENRY
Last Name:BEAUZILE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040-5144
Mailing Address - Country:US
Mailing Address - Phone:413-420-2113
Mailing Address - Fax:
Practice Address - Street 1:230 MAPLE ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-5144
Practice Address - Country:US
Practice Address - Phone:413-420-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-09
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA243330207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110027773BMedicaid
MA001771501Medicare PIN
MAY10009Medicare UPIN