Provider Demographics
NPI:1073502472
Name:BOUDREAUX, CHESTER GREGORY (MD)
Entity type:Individual
Prefix:DR
First Name:CHESTER
Middle Name:GREGORY
Last Name:BOUDREAUX
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 RUE MARGUERITE
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-6738
Mailing Address - Country:US
Mailing Address - Phone:985-446-2131
Mailing Address - Fax:985-447-3383
Practice Address - Street 1:142 RUE MARGUERITE
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-6738
Practice Address - Country:US
Practice Address - Phone:985-446-2131
Practice Address - Fax:985-447-3383
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022212208D00000X
LAMD.022212207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1493783Medicaid
LA1493783Medicaid
5Y480Medicare ID - Type Unspecified