Healthcare Provider Details

I. General information

NPI: 1255666335
Provider Name (Legal Business Name): JOANN MODUPE BOLUDE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2009
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 JEFFERSON HWY
NEW ORLEANS LA
70121-2406
US

IV. Provider business mailing address

105 S. STEWART
COTULLA TX
78014-1013
US

V. Phone/Fax

Practice location:
  • Phone: 504-703-0832
  • Fax: 504-736-4623
Mailing address:
  • Phone: 830-879-3047
  • Fax: 210-277-6387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberQ5763
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberQ5763
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number348591
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: