Provider Demographics
NPI:1710971668
Name:BEAUMONT, ROBERT J (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:BEAUMONT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-4955
Mailing Address - Country:US
Mailing Address - Phone:262-542-5557
Mailing Address - Fax:262-542-6199
Practice Address - Street 1:237 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-4955
Practice Address - Country:US
Practice Address - Phone:262-542-5557
Practice Address - Fax:262-542-6199
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17613207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30036000Medicaid
WIB51442Medicare UPIN
WI000168885Medicare ID - Type Unspecified