Individual
DR. JASON K. BOUDREAU
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.P.M.
Contact information
Practice address
2311 N PROSPECT AVE, MILWAUKEE, WI 53211-4445
(414) 319-3000
Mailing address
4425 N PORT WASHINGTON RD, ATTN: CSMCP CLINIC CREDENTIALING, GLENDALE, WI 53212-1082
(414) 319-3000
Taxonomy
Speciality
Code
Description
License number
State
213E00000X
Podiatrist
Primary
803-025
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
43231600
—
WI
Enumeration date
08/18/2005
Last updated
06/07/2012
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