1407879455 NPI number — DR. JOHN PHILIP BOUDREAUX MD

Table of content: DR. JOHN PHILIP BOUDREAUX MD (NPI 1407879455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407879455 NPI number — DR. JOHN PHILIP BOUDREAUX MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOUDREAUX
Provider First Name:
JOHN
Provider Middle Name:
PHILIP
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407879455
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 W ESPLANADE AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
KENNER
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70065-2489
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-464-8500
Provider Business Mailing Address Fax Number:
504-646-8525

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 W ESPLANADE AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
KENNER
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70065-2489
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-464-8500
Provider Business Practice Location Address Fax Number:
504-464-8525
Provider Enumeration Date:
07/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  014711 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 009932965 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08658853 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1337561 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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