Provider Demographics
NPI:1083664239
Name:BOUDREAUX, CAROLE (MD)
Entity Type:Individual
Prefix:
First Name:CAROLE
Middle Name:
Last Name:BOUDREAUX
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40480
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36640-0480
Mailing Address - Country:US
Mailing Address - Phone:251-471-7790
Mailing Address - Fax:251-471-7715
Practice Address - Street 1:2451 FILLINGIM ST
Practice Address - Street 2:PATHOLOGY
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36617-2238
Practice Address - Country:US
Practice Address - Phone:251-471-7790
Practice Address - Fax:251-471-7715
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL16509207ZC0500X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00118221Medicaid
LA1523593Medicaid
AL51024061OtherBCBS
AL11-10270OtherUNITED HEALTHCARE
AL000024061Medicaid
FL255587500Medicaid
AL11-10270OtherUNITED HEALTHCARE
AL22001974Medicare ID - Type UnspecifiedPGBA RAILROAD
AL000024061Medicaid