Provider Demographics
NPI:1679561195
Name:BEAUDOIN, CLIFFORD (OD)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:
Last Name:BEAUDOIN
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 1:2700 W COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-2918
Mailing Address - Country:US
Mailing Address - Phone:920-735-9580
Mailing Address - Fax:
Practice Address - Street 1:2700 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-2918
Practice Address - Country:US
Practice Address - Phone:920-735-9580
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-10
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2226152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0000437735Medicare ID - Type Unspecified
WIU32684Medicare UPIN