Provider Demographics
NPI:1205983194
Name:BOUDREAUX, KELLY JAMES JR (MD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:JAMES
Last Name:BOUDREAUX
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:8080 BLUEBONNET BLVD
Mailing Address - Street 2:SUITE 3000
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810
Mailing Address - Country:US
Mailing Address - Phone:225-766-8100
Mailing Address - Fax:225-408-6896
Practice Address - Street 1:8080 BLUEBONNET BLVD.
Practice Address - Street 2:SUITE 3000
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810
Practice Address - Country:US
Practice Address - Phone:225-766-8100
Practice Address - Fax:225-408-6896
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2010-08-26
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Provider Licenses
StateLicense IDTaxonomies
LA203731208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
4P066Medicare PIN