Provider Demographics
NPI:1255666335
Name:BOLUDE, JOANN MODUPE (MD)
Entity Type:Individual
Prefix:MS
First Name:JOANN
Middle Name:MODUPE
Last Name:BOLUDE
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 1:105 S. STEWART
Mailing Address - Street 2:
Mailing Address - City:COTULLA
Mailing Address - State:TX
Mailing Address - Zip Code:78014-1013
Mailing Address - Country:US
Mailing Address - Phone:830-879-3047
Mailing Address - Fax:210-277-6387
Practice Address - Street 1:105 S. STEWART
Practice Address - Street 2:
Practice Address - City:COTULLA
Practice Address - State:TX
Practice Address - Zip Code:78014-7801
Practice Address - Country:US
Practice Address - Phone:830-879-3047
Practice Address - Fax:877-992-0112
Is Sole Proprietor?:No
Enumeration Date:2009-10-07
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ5763207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX365574801Medicaid