Healthcare Provider Details

I. General information

NPI: 1053595702
Provider Name (Legal Business Name): KRISTAL BOURGEOIS GUIDROZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2007
Last Update Date: 04/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 BAYOU GARDENS BLVD
HOUMA LA
70364-1434
US

IV. Provider business mailing address

327 BAYOU GARDENS BLVD
HOUMA LA
70364-2635
US

V. Phone/Fax

Practice location:
  • Phone: 985-876-5000
  • Fax: 985-876-5280
Mailing address:
  • Phone: 985-876-5000
  • Fax: 985-876-5280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number202515
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: