Provider Demographics
NPI:1467616201
Name:DOMINIQUE J BEAUDRY MD PA
Entity Type:Organization
Organization Name:DOMINIQUE J BEAUDRY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BEAUDRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-899-2121
Mailing Address - Street 1:3030 NORTH ST
Mailing Address - Street 2:SUITE 312
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1433
Mailing Address - Country:US
Mailing Address - Phone:409-899-2020
Mailing Address - Fax:409-899-2121
Practice Address - Street 1:3030 NORTH ST
Practice Address - Street 2:SUITE 312
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1433
Practice Address - Country:US
Practice Address - Phone:409-899-2020
Practice Address - Fax:409-899-2121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-10
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM9151207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX197371102Medicaid
TX00Z943Medicare PIN