Provider Demographics
NPI:1164503876
Name:BOURDEAU, ELAINE P (OD)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:P
Last Name:BOURDEAU
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19441 GOLF VISTA PLZ
Mailing Address - Street 2:SUITE 320
Mailing Address - City:LANSDOWNE
Mailing Address - State:VA
Mailing Address - Zip Code:20176-8269
Mailing Address - Country:US
Mailing Address - Phone:703-858-9800
Mailing Address - Fax:703-858-9801
Practice Address - Street 1:19441 GOLF VISTA PLZ
Practice Address - Street 2:SUITE 320
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176-8269
Practice Address - Country:US
Practice Address - Phone:703-858-9800
Practice Address - Fax:703-858-9801
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618-000960152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD3461033-03Medicaid
VA9235981Medicaid
MD3461033-01Medicaid
VA119170OtherANTHEM BCBS/HEALTHKEEPERS
VA9235973Medicaid
VA119168OtherANTHEM BCBS/HEALTHKEEPERS
VA119169OtherANTHEM BCBS/HEALTHKEEPERS
VA9235957Medicaid
MD3461033-2Medicaid
VA9235990Medicaid
VA119171OtherANTHEM BCBS/HEALTHKEEPERS
MD3461033-00Medicaid
MD3461033-00Medicaid
MD3461033-01Medicaid
VA119168OtherANTHEM BCBS/HEALTHKEEPERS
MD3461033-2Medicaid