Robert A Boudreau, DPM
Individual provider Active NPI Foot & Ankle Surgery Podiatrist · Tyler, TX
NPI 1326147281 · NPPES record last updated May 18, 2011
Key facts
- NPI
- 1326147281
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Foot & Ankle Surgery Podiatrist 213ES0103X
- License
- 0833 (TX)
- Practice address
- 1028 E Idel
Suite a
Tyler, TX 75701 - Phone
- (903) 593-1749
- Fax
- (903) 593-1749
- NPI assigned
- Sep 21, 2006
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 3
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in TX
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20080711000372 | TX | Practitioner - Podiatry | 2466524194 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Starks Medical | Past | Accepting new patients | |
| East Texas Medical Center Healthcare Associates | Past | Accepting new patients | |
| East Texas Podiatry Associates, P.C. | Foot & Ankle Surgery | Past |
Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Foot & Ankle Surgery Podiatrist | 213ES0103X | 0833 | TX | Yes |
Addresses
Primary practice location
1028 E Idel
Suite a
Tyler, TX 75701
Mailing address
1028 E Idel
Suite a
Tyler, TX 75701
Phone (903) 593-1749
NPI Registry JSON
{
"created_epoch": "1158796800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1305676800000",
"number": "1326147281",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1028 E IDEL",
"address_2": "SUITE A",
"city": "TYLER",
"state": "TX",
"postal_code": "75701",
"telephone_number": "903-593-1749",
"fax_number": "903-593-1749"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1028 E IDEL",
"address_2": "SUITE A",
"city": "TYLER",
"state": "TX",
"postal_code": "75701",
"telephone_number": "903-593-1749",
"fax_number": "903-593-1749"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BOUDREAU",
"first_name": "ROBERT",
"middle_name": "A",
"credential": "DPM",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-09-21",
"last_updated": "2011-05-18",
"status": "A"
},
"taxonomies": [
{
"code": "213ES0103X",
"taxonomy_group": "",
"desc": "Podiatrist, Foot & Ankle Surgery",
"state": "TX",
"license": "0833",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Tyler, TX
- Aryana Bosh
- Sarah Elizabeth Bostick
- Amber Lynn Boswell
- Carla Boswell
- Michele C Bosworth
- Coby Bounds
- Yullyza Maria Bouza
- Billie Ruth Bowen
- David Marcos Bowen
- Alicia Bowles
All providers in Tyler, TX · Foot & Ankle Surgery Podiatrist in Texas
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 18, 2011. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.