Basic Information
| Provider Information | |||||||||
| NPI: | 1114218633 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOUADOU | ||||||||
| FirstName: | JEFFERY | ||||||||
| MiddleName: | LEROY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 316 N BROAD ST | ||||||||
| Address2: | |||||||||
| City: | WINDER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306802150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708673400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307202529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062172207 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2011 | ||||||||
| LastUpdateDate: | 01/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 071932 | GA | N | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | 071932 | GA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.