Provider Demographics
NPI:1720053200
Name:BEAUDETTE, PETER THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:THOMAS
Last Name:BEAUDETTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7110 WYOMING BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4867
Mailing Address - Country:US
Mailing Address - Phone:505-346-0500
Mailing Address - Fax:
Practice Address - Street 1:7110 WYOMING BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4867
Practice Address - Country:US
Practice Address - Phone:505-346-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM77129207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM11399OtherPRESBYTERIAN HEALTH PLAN
NM00002030Medicaid
NM00002030Medicaid
NM11399OtherPRESBYTERIAN HEALTH PLAN
NMA3558Medicare UPIN