Provider Demographics
NPI:1659834323
Name:BOUDREAU, MARK RICARD JR (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:RICARD
Last Name:BOUDREAU
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E 2ND AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3210
Mailing Address - Country:US
Mailing Address - Phone:706-509-3000
Mailing Address - Fax:
Practice Address - Street 1:304 SHORTER AVE NW STE 105
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-4256
Practice Address - Country:US
Practice Address - Phone:706-236-4880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11273208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program