Provider Demographics
NPI:1972895886
Name:BOUDREAUX, BEAU DAVID (MD)
Entity Type:Individual
Prefix:
First Name:BEAU
Middle Name:DAVID
Last Name:BOUDREAUX
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 5478
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70302-5478
Mailing Address - Country:US
Mailing Address - Phone:985-449-4656
Mailing Address - Fax:985-449-2532
Practice Address - Street 1:726 N ACADIA RD STE 3400
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-5009
Practice Address - Country:US
Practice Address - Phone:985-449-4656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LAMD.207047207RR0500X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2153200Medicaid