Provider Demographics
NPI:1114133006
Name:BEAUDOIN, BRIAN (PT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:BEAUDOIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 REDWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CORTE MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:94925-1572
Mailing Address - Country:US
Mailing Address - Phone:415-924-7757
Mailing Address - Fax:415-924-9725
Practice Address - Street 1:208 REDWOOD AVE
Practice Address - Street 2:
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1572
Practice Address - Country:US
Practice Address - Phone:415-924-7757
Practice Address - Fax:415-924-9725
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA010827225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT108240Medicare ID - Type Unspecified
CAR24495Medicare UPIN