Provider Demographics
NPI:1205240835
Name:BEAUDETT, ETHAN NERE (DO)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:NERE
Last Name:BEAUDETT
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 1:738 LIBRARY ROAD
Mailing Address - Street 2:PO BOX 270617
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14627-0617
Mailing Address - Country:US
Mailing Address - Phone:585-275-2662
Mailing Address - Fax:585-276-0149
Practice Address - Street 1:738 LIBRARY ROAD
Practice Address - Street 2:#1
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14627-0617
Practice Address - Country:US
Practice Address - Phone:585-275-2662
Practice Address - Fax:585-276-0149
Is Sole Proprietor?:No
Enumeration Date:2014-06-11
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY290946207Q00000X, 207QS0010X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program