Provider Demographics
NPI:1386673648
Name:COURTEMANCHE, BRIAN PAUL (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:PAUL
Last Name:COURTEMANCHE
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 1:230 NORTH MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-2004
Mailing Address - Country:US
Mailing Address - Phone:860-646-4083
Mailing Address - Fax:860-647-1733
Practice Address - Street 1:230 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-2004
Practice Address - Country:US
Practice Address - Phone:860-646-4083
Practice Address - Fax:860-647-1733
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002567152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004218287Medicaid
CT410047532OtherMEDICARE RAILROAD
CT410001022Medicare PIN
CTU85967Medicare UPIN