Provider Demographics
NPI:1457312183
Name:BOURGEOIS, KEITH ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ALAN
Last Name:BOURGEOIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1315 ST JOSEPH PKWY
Mailing Address - Street 2:SUITE 1601
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77002-8233
Mailing Address - Country:US
Mailing Address - Phone:713-650-0391
Mailing Address - Fax:713-650-0395
Practice Address - Street 1:1315 ST JOSEPH PKWY
Practice Address - Street 2:SUITE 1601
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77002-8233
Practice Address - Country:US
Practice Address - Phone:713-650-0391
Practice Address - Fax:713-650-0395
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXG7625207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP085170J07Medicaid
TXB21421Medicare UPIN
TXP085170J07Medicaid