1528148889 NPI number — DR. SUSAN L BOULLIOUN MD

Table of content: DR. SUSAN L BOULLIOUN MD (NPI 1528148889)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528148889 NPI number — DR. SUSAN L BOULLIOUN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOULLIOUN
Provider First Name:
SUSAN
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1528148889
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
113 E CEDAR ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEGUIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78155-3709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-303-3500
Provider Business Mailing Address Fax Number:
830-303-9399

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
113 E CEDAR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEGUIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78155-3709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-303-3500
Provider Business Practice Location Address Fax Number:
830-303-9399
Provider Enumeration Date:
10/17/2006

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: 207Q00000X , with the licence number:  K2312 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 121420704 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 205495901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 121420705 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com