Provider Demographics
NPI:1588801609
Name:SUSAN L. BOULLIOUN, M.D., P.A.
Entity Type:Organization
Organization Name:SUSAN L. BOULLIOUN, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:LORTON
Authorized Official - Last Name:BOULLIOUN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:830-303-3500
Mailing Address - Street 1:113 E CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78155-3709
Mailing Address - Country:US
Mailing Address - Phone:830-303-3500
Mailing Address - Fax:830-303-9399
Practice Address - Street 1:113 E. CEDAR ST.
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-3709
Practice Address - Country:US
Practice Address - Phone:830-303-3500
Practice Address - Fax:830-303-9399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-12
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2312207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121420704Medicaid
TX121420702Medicaid
TX121420704Medicaid