Provider Demographics
NPI:1457342842
Name:BOURGEOIS, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BOURGEOIS
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 5865
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79408-5865
Mailing Address - Country:US
Mailing Address - Phone:806-743-2898
Mailing Address - Fax:806-743-2787
Practice Address - Street 1:4102 24TH ST STE 507
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1805
Practice Address - Country:US
Practice Address - Phone:806-743-7334
Practice Address - Fax:806-743-7332
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF5842208M00000X, 2080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX460001727OtherRAILROAD
NMA119OtherTRIWEST
TX138369704Medicaid
NMV2944Medicaid
OK100086010BMedicaid
NM36233OtherPRESBYTERIAN COMMERCIAL
TX108958105OtherFIRSTCARE COMMERCIAL
TX138369711Medicaid
NM36233Medicaid
TX89C152OtherBC/BS
TX80822ZOtherHMO BLUE
TX138369711Medicaid
OK100086010BMedicaid