Provider Demographics
NPI:1164643797
Name:BEAUDETTE, EDWARD (LO)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:
Last Name:BEAUDETTE
Suffix:
Gender:M
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 STATE ST
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06517-3721
Mailing Address - Country:US
Mailing Address - Phone:203-288-4905
Mailing Address - Fax:203-288-4905
Practice Address - Street 1:2301 STATE ST
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06517-3721
Practice Address - Country:US
Practice Address - Phone:203-288-4905
Practice Address - Fax:203-288-4905
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1001156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CU8360OtherHEALTHNET
100001001CT02OtherANTHEM
CT004054029Medicaid
CT1001OtherEYEMED
CT0563580001Medicare NSC