Healthcare Provider Details

I. General information

NPI: 1245440577
Provider Name (Legal Business Name): MATTHEW B BOUDREAUX M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 10/01/2021
Certification Date: 10/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 DRURY LN
LAFAYETTE LA
70508-5702
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 337-233-0219
  • Fax: 337-233-2418
Mailing address:
  • Phone: 337-233-0219
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number202133
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: