Healthcare Provider Details

I. General information

NPI: 1467423913
Provider Name (Legal Business Name): BRENT BOUDREAUX MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 02/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 GREENWOOD RD
SHREVEPORT LA
71103-3908
US

IV. Provider business mailing address

PO BOX 9600 DEPT 09-033
TEXARKANA TX
75505-9600
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-4550
  • Fax:
Mailing address:
  • Phone: 877-243-8416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number017805
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: