Healthcare Provider Details

I. General information

NPI: 1053413583
Provider Name (Legal Business Name): LEONARD JB BOURGEOIS SR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 CHURCH ST
JEANERETTE LA
70544-4407
US

IV. Provider business mailing address

PO BOX 910
JEANERETTE LA
70544-0910
US

V. Phone/Fax

Practice location:
  • Phone: 337-276-6018
  • Fax: 337-276-9507
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number017806
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: