Provider Demographics
NPI:1487140828
Name:BOUDOUSQUIE, LAUREN MORIAH (OD)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:MORIAH
Last Name:BOUDOUSQUIE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:MORIAH
Other - Last Name:SHACKELFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:500 MARKAVIEW RD NW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35805-3652
Mailing Address - Country:US
Mailing Address - Phone:256-533-8477
Mailing Address - Fax:
Practice Address - Street 1:700 19TH ST S # 124
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1927
Practice Address - Country:US
Practice Address - Phone:205-933-8101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-09
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-E16152W00000X
NC2549152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty