=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609057884
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID JEAN-GUY BOUDREAULT M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2007
-----------------------------------------------------
Last Update Date | 05/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1515 EL CAMINO REAL STE C
-----------------------------------------------------
City | PALO ALTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94306-1000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-433-8621
-----------------------------------------------------
Fax | 650-434-0061
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1515 EL CAMINO REAL STE C
-----------------------------------------------------
City | PALO ALTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94306-1000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-433-8621
-----------------------------------------------------
Fax | 650-434-0061
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | A98186
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------