Provider Demographics
NPI:1528014461
Name:BOUDREAU, EDWARD DAVID (DO)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:DAVID
Last Name:BOUDREAU
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 578
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE WELLS
Mailing Address - State:CO
Mailing Address - Zip Code:80810-0578
Mailing Address - Country:US
Mailing Address - Phone:719-767-5662
Mailing Address - Fax:719-451-3423
Practice Address - Street 1:615 W 5TH ST N
Practice Address - Street 2:
Practice Address - City:CHEYENNE WELLS
Practice Address - State:CO
Practice Address - Zip Code:80810
Practice Address - Country:US
Practice Address - Phone:719-767-5661
Practice Address - Fax:719-767-5098
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0063534207P00000X, 207P00000X
CODR.0063534207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHA80326Medicare UPIN