Provider Demographics
NPI:1679680557
Name:BEAULIEU, NICHOLAS JEAN (MD)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:JEAN
Last Name:BEAULIEU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:NICHOLAS
Other - Middle Name:JEAN
Other - Last Name:BEAULIEU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:920 PONCE DE LEON AVE NE
Mailing Address - Street 2:920 PONCE DE LEON AVE
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-4212
Mailing Address - Country:US
Mailing Address - Phone:404-815-1957
Mailing Address - Fax:404-815-1954
Practice Address - Street 1:920 PONCE DE LEON AVE NE
Practice Address - Street 2:920 PONCE DE LEON AVE
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30306-4212
Practice Address - Country:US
Practice Address - Phone:404-815-1957
Practice Address - Fax:404-815-1954
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA42176305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00717076EMedicaid
GAG24941Medicare UPIN
GA00717076EMedicaid