Provider Demographics
NPI:1629026406
Name:LE BOEUF, BRANDI CHERI (MD)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:CHERI
Last Name:LE BOEUF
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 1:2600 LAKE AUSTIN BLVD
Mailing Address - Street 2:#15102
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703-4440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 W 38TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1006
Practice Address - Country:US
Practice Address - Phone:512-324-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8792207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170021301Medicaid
TX170021302Medicaid
TX8D6390Medicare PIN
TX170021302Medicaid
TX8C2590Medicare PIN
TXI16521Medicare UPIN
TXP00158333Medicare PIN