MEDICARE: DR. SUSAN L BOULLIOUN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	K2312	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528148889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN L BOULLIOUN MD

Provider Business Mailing Address
First Line	:	113 E CEDAR ST
Second Line	:
City	:	SEGUIN
State	:	TX
Zip	:	78155-3709
Country	:	US
Telephone Number	:	830-303-3500
Fax Number	:	830-303-9399

Provider Business Practice Location Address
First Line	:	113 E CEDAR ST
Second Line	:
City	:	SEGUIN
State	:	TX
Zip	:	78155-3709
Country	:	US
Telephone Number	:	830-303-3500
Fax Number	:	830-303-9399

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2006
Last Update Date	:	06/10/2026

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