Provider Demographics
NPI:1528148889
Name:BOULLIOUN, SUSAN L (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:L
Last Name:BOULLIOUN
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 1:113 E CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78155-3709
Mailing Address - Country:US
Mailing Address - Phone:830-303-3500
Mailing Address - Fax:830-303-9399
Practice Address - Street 1:113 E CEDAR ST
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-3709
Practice Address - Country:US
Practice Address - Phone:830-303-3500
Practice Address - Fax:830-303-9399
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2312207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121420704Medicaid
TX205495901Medicaid
TX121420705Medicaid
TX121420705Medicaid