Healthcare Provider Details

I. General information

NPI: 1679680557
Provider Name (Legal Business Name): NICHOLAS JEAN BEAULIEU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: NICHOLAS JEAN BEAULIEU M.D.

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 09/29/2022
Certification Date: 09/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 PONCE DE LEON AVE NE 920 PONCE DE LEON AVE
ATLANTA GA
30306-4212
US

IV. Provider business mailing address

920 PONCE DE LEON AVE NE 920 PONCE DE LEON AVE
ATLANTA GA
30306-4212
US

V. Phone/Fax

Practice location:
  • Phone: 404-815-1957
  • Fax: 404-815-1954
Mailing address:
  • Phone: 404-815-1957
  • Fax: 404-815-1954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number42176
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: