Provider Demographics
NPI:1043568991
Name:BOURGEOIS, DANIEL JOSEPH III (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JOSEPH
Last Name:BOURGEOIS
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1120 ROBERT BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-2068
Mailing Address - Country:US
Mailing Address - Phone:985-280-8688
Mailing Address - Fax:985-280-6642
Practice Address - Street 1:1120 ROBERT BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2068
Practice Address - Country:US
Practice Address - Phone:985-280-8868
Practice Address - Fax:985-280-6642
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.3044712085R0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2437461Medicaid