Healthcare Provider Details

I. General information

NPI: 1457312183
Provider Name (Legal Business Name): KEITH ALAN BOURGEOIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 ST JOSEPH PKWY SUITE 1601
HOUSTON TX
77002-8233
US

IV. Provider business mailing address

1315 ST JOSEPH PKWY SUITE 1601
HOUSTON TX
77002-8233
US

V. Phone/Fax

Practice location:
  • Phone: 713-650-0391
  • Fax: 713-650-0395
Mailing address:
  • Phone: 713-650-0391
  • Fax: 713-650-0395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberG7625
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberG7625
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: