Provider Demographics
NPI:1912093709
Name:BOURQUE, THAD ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:THAD
Middle Name:ALEXANDER
Last Name:BOURQUE
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 1:120 RUE LOUIS XIV
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-5783
Mailing Address - Country:US
Mailing Address - Phone:337-769-7779
Mailing Address - Fax:337-769-7800
Practice Address - Street 1:1103 KALISTE SALOOM RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-5783
Practice Address - Country:US
Practice Address - Phone:337-988-1803
Practice Address - Fax:337-988-1805
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021311174400000X
LAMD.021311208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAC5115OtherBLUE CROSS BLUE SHIELD
LA1680974Medicaid
LA1680974Medicaid
LAC5115OtherBLUE CROSS BLUE SHIELD
LA5W832Medicare PIN