Provider Demographics
NPI:1235279993
Name:BEAUCLAIR, MICHAEL JOSEPH (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:BEAUCLAIR
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 BLOSSOM PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-4401
Mailing Address - Country:US
Mailing Address - Phone:216-226-4694
Mailing Address - Fax:
Practice Address - Street 1:1415 BLOSSOM PARK AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4401
Practice Address - Country:US
Practice Address - Phone:216-226-4694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002647213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0814828Medicaid
OH0814828Medicaid
OHBE0688991Medicare ID - Type Unspecified