Provider Demographics
NPI:1568473486
Name:BOUDREAUX, ILENE (MD)
Entity Type:Individual
Prefix:DR
First Name:ILENE
Middle Name:
Last Name:BOUDREAUX
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3521 SILVERSIDE RD
Mailing Address - Street 2:1F QUILLEN BLDG
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19810-4900
Mailing Address - Country:US
Mailing Address - Phone:302-479-5505
Mailing Address - Fax:302-478-2637
Practice Address - Street 1:3521 SILVERSIDE RD
Practice Address - Street 2:1F QUILLEN BLDG
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19810-4900
Practice Address - Country:US
Practice Address - Phone:302-479-5505
Practice Address - Fax:302-478-2637
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10003341208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000129401Medicaid
DE0000129401Medicaid