Provider Demographics
NPI:1528183068
Name:BOUSTANY, RITA (MD)
Entity Type:Individual
Prefix:MS
First Name:RITA
Middle Name:
Last Name:BOUSTANY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:RITA
Other - Middle Name:
Other - Last Name:AL-BOUSTANI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PEDIATRIX - P.O. BOX 60612
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70596-0612
Mailing Address - Country:US
Mailing Address - Phone:337-330-0031
Mailing Address - Fax:
Practice Address - Street 1:PEDIATRIX - 4600 AMBASSADOR CAFFERY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508
Practice Address - Country:US
Practice Address - Phone:337-330-0031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA37117208000000X
LAMD.203808208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2116436Medicaid
IA56768OtherWELLMARK