Provider Demographics
NPI:1225123839
Name:BOUDREAUX, MANDY LYNN (MD)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:LYNN
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:P O BOX 1152
Mailing Address - Street 2:
Mailing Address - City:ABBEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70511-1152
Mailing Address - Country:US
Mailing Address - Phone:337-893-6294
Mailing Address - Fax:337-893-6369
Practice Address - Street 1:118 N HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:ABBEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70510-4039
Practice Address - Country:US
Practice Address - Phone:337-893-6294
Practice Address - Fax:337-893-6369
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA201161207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1706639Medicaid
LAUPIN # I64230OtherUPIN #
LAUPIN # I64230OtherUPIN #