Provider Demographics
NPI:1790715209
Name:BEVILACQUA, PAULA MICHELE (MD)
Entity Type:Individual
Prefix:DR
First Name:PAULA
Middle Name:MICHELE
Last Name:BEVILACQUA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-3158
Mailing Address - Country:US
Mailing Address - Phone:203-250-7577
Mailing Address - Fax:203-250-0739
Practice Address - Street 1:677 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-3158
Practice Address - Country:US
Practice Address - Phone:203-250-7577
Practice Address - Fax:203-250-0739
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT029901207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E43611Medicare UPIN