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NPI Code Detail

MEDICARE: DR. CORY JAMES BOUDREAUX O.D.

MEDICARE: DR. CORY JAMES BOUDREAUX O.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1152W00000XOptometrist1563-594TLA

General Provider Information

NPI Number : 1790940096
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. CORY JAMES BOUDREAUX O.D.
Provider Business Mailing Address
First Line : 2308 S BURNSIDE AVE
Second Line :
City : GONZALES
State : LA
Zip : 70737-4643
Country : US
Telephone Number : 225-644-7525
Fax Number : 225-647-3710
Provider Business Practice Location Address
First Line : 2308 S BURNSIDE AVE
Second Line :
City : GONZALES
State : LA
Zip : 70737-4643
Country : US
Telephone Number : 225-644-7525
Fax Number : 225-647-3710
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/25/2008
Last Update Date : 08/04/2022

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