Provider Demographics
NPI:1811063894
Name:BOUDREAUX, DANIEL J (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:J
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:PO BOX 48089
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30604-8089
Mailing Address - Country:US
Mailing Address - Phone:706-389-3740
Mailing Address - Fax:706-389-3951
Practice Address - Street 1:1230 BAXTER ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-3712
Practice Address - Country:US
Practice Address - Phone:706-389-2400
Practice Address - Fax:706-389-2401
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA58150207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52229995OtherBCBSGA
SCG58150Medicaid
SCG58150Medicaid
SCG58150Medicaid
511I220017Medicare PIN
GAVAD 000Medicare UPIN