Basic Information
Provider Information
NPI: 1003015173
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BEAUCHAMP BRUNO
FirstName: MAYRA
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: BEAUCHAMP BRUNO
OtherFirstName: MAYRA
OtherMiddleName: CRISTINA
OtherNamePrefix: DR.
OtherNameSuffix:  
OtherCredential: M.D.
OtherLastNameType: 5
Mailing Information
Address1: 253 PLEASANT ST
Address2:  
City: CONCORD
State: NH
PostalCode: 033017560
CountryCode: US
TelephoneNumber: 6032262200
FaxNumber:  
Practice Location
Address1: 253 PLEASANT ST
Address2:  
City: CONCORD
State: NH
PostalCode: 033017560
CountryCode: US
TelephoneNumber: 6032262200
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/17/2007
LastUpdateDate: 03/09/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207N00000X16259NHY Allopathic & Osteopathic PhysiciansDermatology 
207N00000X17621PRN Allopathic & Osteopathic PhysiciansDermatology 

ID Information
IDTypeStateIssuerDescription
309108205NH MEDICAID


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