Provider Demographics
NPI:1164418513
Name:BEAULAURIER, BRUCE A (OD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:BEAULAURIER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12310 NE 8TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-3185
Mailing Address - Country:US
Mailing Address - Phone:425-455-0001
Mailing Address - Fax:
Practice Address - Street 1:12310 NE 8TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-3185
Practice Address - Country:US
Practice Address - Phone:425-455-0001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1464152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2030328Medicaid
WA2030328Medicaid
WAU28594Medicare UPIN
WA0551250001Medicare NSC