Provider Demographics
NPI:1982664371
Name:BOUDREAUX, DAVID A
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
Last Name:BOUDREAUX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5339 ODONAVAN
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4388
Mailing Address - Country:US
Mailing Address - Phone:225-766-4999
Mailing Address - Fax:225-763-5870
Practice Address - Street 1:5339 ODONAVAN
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4388
Practice Address - Country:US
Practice Address - Phone:225-766-4999
Practice Address - Fax:225-763-5870
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.012883207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1389561Medicaid
LA1389561Medicaid
LAB61771Medicare UPIN