Provider Demographics
NPI:1649582586
Name:POQUETTE, BEAU DAVID (OD)
Entity Type:Individual
Prefix:
First Name:BEAU
Middle Name:DAVID
Last Name:POQUETTE
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 1:200 FAIRBANKS ST
Mailing Address - Street 2:STE 1
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-1510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 FAIRBANKS ST
Practice Address - Street 2:STE 1
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-1510
Practice Address - Country:US
Practice Address - Phone:906-774-8280
Practice Address - Fax:906-774-8290
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004595152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist