Healthcare Provider Details

I. General information

NPI: 1528183068
Provider Name (Legal Business Name): RITA BOUSTANY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RITA AL-BOUSTANI M.D.

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70508-6902
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 337-470-2605
  • Fax: 337-470-4595
Mailing address:
  • Phone: 337-470-2605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number37117
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD.203808
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: