Basic Information
| Provider Information | |||||||||
| NPI: | 1225264096 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEAULIEU | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4351 TAMIAMI TRL N | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341033106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392631777 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4351 TAMIAMI TRL N | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341033106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2932631777 | ||||||||
| FaxNumber: | 2392636983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2009 | ||||||||
| LastUpdateDate: | 07/27/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | ME123635 | FL | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZB0001X | ME123635 | FL | N | Allopathic & Osteopathic Physicians | Pathology | Blood Banking & Transfusion Medicine | 207ZH0000X | ME123635 | FL | N | Allopathic & Osteopathic Physicians | Pathology | Hematology |
ID Information
| ID | Type | State | Issuer | Description | LL36525 | 01 | SC | MEDICAL LICENSE | OTHER | MD039336 | 01 | DC | MEDICAL LICENSE | OTHER | 014812400 | 05 | FL | MEDICAID | FB5175585 | 01 | DEA REGISTRATION NUMBER | OTHER | ME123635 | 01 | FL | MEDICAL LICENSE | OTHER |