Provider Demographics
NPI:1417376013
Name:BOURLA, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BOURLA
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 1:1430 TULANE AVE.
Mailing Address - Street 2:SL-50
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-2699
Mailing Address - Country:US
Mailing Address - Phone:504-988-7809
Mailing Address - Fax:504-988-3971
Practice Address - Street 1:1430 TULANE AVE.
Practice Address - Street 2:SL-50
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-2699
Practice Address - Country:US
Practice Address - Phone:504-988-7809
Practice Address - Fax:504-988-3971
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-10
Last Update Date:2017-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA305567207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program