Provider Demographics
NPI:1730110263
Name:BOUCREE, JOSEPH B JR (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:B
Last Name:BOUCREE
Suffix:JR
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 1:1570 LINDBERG DR STE 8
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-8084
Mailing Address - Country:US
Mailing Address - Phone:985-205-3456
Mailing Address - Fax:985-288-0047
Practice Address - Street 1:1570 LINDBERG DR STE 8
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-8084
Practice Address - Country:US
Practice Address - Phone:985-205-3456
Practice Address - Fax:985-288-0047
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA020305174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1182257Medicaid
LA5H984Medicare ID - Type Unspecified
LA1182257Medicaid