Provider Demographics
NPI:1750338380
Name:BEAUDRY, CARL JOSEPH (MD)
Entity type:Individual
Prefix:MR
First Name:CARL
Middle Name:JOSEPH
Last Name:BEAUDRY
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 1:2501 JIMMY JOHNSON BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77640-2007
Mailing Address - Country:US
Mailing Address - Phone:409-722-4446
Mailing Address - Fax:409-722-4448
Practice Address - Street 1:2501 JIMMY JOHNSON BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77640-2007
Practice Address - Country:US
Practice Address - Phone:409-722-4446
Practice Address - Fax:409-722-4448
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE9531174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX097777901Medicaid
TXE9531OtherPHYSICIAN PERMIT
TX687562OtherAETNA
TXCIGNAOther3739015001
TX0082GSOtherBLUE CROSS
TXS0033018OtherDPS
TXS0033018OtherDPS
TXCIGNAOther3739015001
TXAB7974365OtherDEA
TXB21146Medicare UPIN