Provider Demographics
NPI:1063602431
Name:BOURGEOIS, TIFFANY MOORE (MD)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MOORE
Last Name:BOURGEOIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 POINTE SOUTH DR
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-5426
Mailing Address - Country:US
Mailing Address - Phone:225-202-0946
Mailing Address - Fax:
Practice Address - Street 1:8212 SUMMA AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3421
Practice Address - Country:US
Practice Address - Phone:225-769-4403
Practice Address - Fax:225-769-3842
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.202681207L00000X
NC2011-00769207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1000892Medicaid