Healthcare Provider Details

I. General information

NPI: 1932109451
Provider Name (Legal Business Name): MICHAEL WILFRED PROSPER BOOS JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2005
Last Update Date: 09/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4640 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70508-6902
US

IV. Provider business mailing address

4640 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70508-6902
US

V. Phone/Fax

Practice location:
  • Phone: 337-984-1050
  • Fax: 337-984-8776
Mailing address:
  • Phone: 337-984-1050
  • Fax: 337-984-8776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number13759
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: