Provider Demographics
NPI:1053413583
Name:BOURGEOIS, LEONARD JB SR (MD)
Entity type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:JB
Last Name:BOURGEOIS
Suffix:SR
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 910
Mailing Address - Street 2:
Mailing Address - City:JEANERETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70544-0910
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1409 CHURCH ST
Practice Address - Street 2:
Practice Address - City:JEANERETTE
Practice Address - State:LA
Practice Address - Zip Code:70544-4407
Practice Address - Country:US
Practice Address - Phone:337-276-6018
Practice Address - Fax:337-276-9507
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017806207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1365831Medicaid
LA52187Medicare ID - Type Unspecified
LA1365831Medicaid