Provider Demographics
NPI:1598720617
Name:BOUDREAU, DOUGLAS A (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:A
Last Name:BOUDREAU
Suffix:
Gender:M
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:PO BOX 1520
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31310-8520
Mailing Address - Country:US
Mailing Address - Phone:912-318-3947
Mailing Address - Fax:912-587-7018
Practice Address - Street 1:303 FRASER DR
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-3712
Practice Address - Country:US
Practice Address - Phone:912-877-2227
Practice Address - Fax:912-877-2332
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA90555208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
440546366OtherUNITED HEALTHCARE
PC10371OtherCIGNA
1724934OtherFIRST HEALTH
MO204659403Medicaid
H00943OtherMERCY
MO207515500OtherMEDICAID
411755OtherHEALTHLINK
7609055OtherAETNA
124669OtherBLUE CROSS BLUE SHIELD
MO204659403OtherMEDICAID
H00943Medicare UPIN