Provider Demographics
NPI:1497785117
Name:BOUDREAUX, CRAIG S (DO)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:S
Last Name:BOUDREAUX
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 S LOOP 336 W STE 200
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-3320
Mailing Address - Country:US
Mailing Address - Phone:936-525-3600
Mailing Address - Fax:936-525-3624
Practice Address - Street 1:1169 GRAND CENTRAL PKWY
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-3185
Practice Address - Country:US
Practice Address - Phone:936-525-3600
Practice Address - Fax:936-525-3624
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4639207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8K5426OtherBLUE CROSS BLUE SHIELD
TX8D0626Medicare ID - Type Unspecified
G89923Medicare UPIN