Basic Information
| Provider Information | |||||||||
| NPI: | 1255666335 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLUDE | ||||||||
| FirstName: | JOANN | ||||||||
| MiddleName: | MODUPE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 S. STEWART | ||||||||
| Address2: | |||||||||
| City: | COTULLA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780141013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8308793047 | ||||||||
| FaxNumber: | 2102776387 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 S. STEWART | ||||||||
| Address2: | |||||||||
| City: | COTULLA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780147801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8308793047 | ||||||||
| FaxNumber: | 8779920112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2009 | ||||||||
| LastUpdateDate: | 01/02/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Q5763 | TX | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 365574801 | 05 | TX | MEDICAID |