Healthcare Provider Details

I. General information

NPI: 1215923941
Provider Name (Legal Business Name): JAMES ANTHONY BOUDREAU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: TONY BOUDREAU MD

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date: 03/25/2006
Reactivation Date: 04/06/2006

III. Provider practice location address

2705 N LEBANON ST STE 300
LEBANON IN
46052-8622
US

IV. Provider business mailing address

2605 N LEBANON ST
LEBANON IN
46052-1476
US

V. Phone/Fax

Practice location:
  • Phone: 765-485-8649
  • Fax: 765-485-8650
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01053439A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: