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General NPI Number Information
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NPI Number | 1588801609
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Entity Type | Organization
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Legal Business Name | SUSAN L. BOULLIOUN, M.D., P.A.
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Dates
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Enumeration Date | 01/12/2009
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Last Update Date | 01/07/2010
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Provider Practice Location Address
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Address Line | 113 E. CEDAR ST.
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City | SEGUIN
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State | TX
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Zip | 78155-3709
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Country | US
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Telephone | 830-303-3500
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Fax | 830-303-9399
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Provider Business Mailing Address
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Address Line | 113 E CEDAR ST
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City | SEGUIN
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State | TX
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Zip | 78155-3709
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Country | US
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Telephone | 830-303-3500
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Fax | 830-303-9399
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SUSAN LORTON BOULLIOUN
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Credential | M.D.
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Telephone | 830-303-3500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | K2312
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License Number State | TX
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