Provider Demographics
NPI:1922502772
Name:BOURGEOIS, TRACI (MD)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:BOURGEOIS
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 1:324 DULLES DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506
Mailing Address - Country:US
Mailing Address - Phone:337-706-1571
Mailing Address - Fax:337-261-2697
Practice Address - Street 1:2390 WEST CONGRESS STREET
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506
Practice Address - Country:US
Practice Address - Phone:337-261-6000
Practice Address - Fax:337-261-6003
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA326107207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2465104Medicaid