Provider Demographics
NPI:1649241506
Name:GAUDREAU, DAVID B (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:B
Last Name:GAUDREAU
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 1:169 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-2115
Mailing Address - Country:US
Mailing Address - Phone:860-963-2020
Mailing Address - Fax:860-928-2040
Practice Address - Street 1:169 GROVE ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-2115
Practice Address - Country:US
Practice Address - Phone:860-963-2020
Practice Address - Fax:860-928-2040
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002090152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0523550001Medicare NSC
CTT23111Medicare UPIN
P00068566Medicare PIN