Provider Demographics
NPI:1407879455
Name:BOUDREAUX, JOHN PHILIP (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PHILIP
Last Name:BOUDREAUX
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 1:200 W ESPLANADE AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-2489
Mailing Address - Country:US
Mailing Address - Phone:504-464-8500
Mailing Address - Fax:504-646-8525
Practice Address - Street 1:200 W ESPLANADE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-2489
Practice Address - Country:US
Practice Address - Phone:504-464-8500
Practice Address - Fax:504-464-8525
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA014711208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009932965Medicaid
MS08658853Medicaid
LA1337561Medicaid
LA5N062F669Medicare PIN
D47967Medicare UPIN
LA1337561Medicaid
LA5N062F668Medicare PIN
AL009932965Medicaid