=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972895886
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BEAU DAVID BOUDREAUX M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2011
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 726 N ACADIA RD STE 3400
-----------------------------------------------------
City | THIBODAUX
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70301-5009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-449-4656
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5478
-----------------------------------------------------
City | THIBODAUX
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70302-5478
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-449-4656
-----------------------------------------------------
Fax | 985-449-2532
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | MD.207047
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | MD.207047
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------