Provider Demographics
NPI:1649291238
Name:BOUDREAUX, STEPHEN ANTHONY (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ANTHONY
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 1:520 N LEWIS ST STE 203
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70563-2094
Mailing Address - Country:US
Mailing Address - Phone:337-364-3444
Mailing Address - Fax:337-364-3224
Practice Address - Street 1:520 N LEWIS ST STE 203
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70563-2094
Practice Address - Country:US
Practice Address - Phone:337-364-3444
Practice Address - Fax:337-364-3224
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA014239207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1906336Medicaid
LA50215CG60Medicare PIN
LA1906336Medicaid
LAB62248Medicare UPIN
LA50215DE05Medicare PIN