Provider Demographics
NPI:1154321297
Name:BOURGEOIS, MELVIN G (MD)
Entity Type:Individual
Prefix:
First Name:MELVIN
Middle Name:G
Last Name:BOURGEOIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 KENNETH ST
Mailing Address - Street 2:
Mailing Address - City:MORGAN CITY
Mailing Address - State:LA
Mailing Address - Zip Code:70380-1353
Mailing Address - Country:US
Mailing Address - Phone:985-384-3355
Mailing Address - Fax:985-384-2884
Practice Address - Street 1:1201 KENNETH ST
Practice Address - Street 2:
Practice Address - City:MORGAN CITY
Practice Address - State:LA
Practice Address - Zip Code:70380-1353
Practice Address - Country:US
Practice Address - Phone:985-384-3355
Practice Address - Fax:985-384-2884
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09057207Q00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B60412Medicare UPIN
LA5J297D226Medicare ID - Type Unspecified