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NPI Code Detail

MEDICARE: MR. SHANNON CHRISTOPHER BOUDREAUX MD

MEDICARE: MR. SHANNON CHRISTOPHER BOUDREAUX MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1208000000XPediatrics PhysicianME95353FL
2207P00000XEmergency Medicine PhysicianME95353FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1245285824
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. SHANNON CHRISTOPHER BOUDREAUX MD
Provider Business Mailing Address
First Line : 1601 CUMMINS DR STE D
Second Line :
City : MODESTO
State : CA
Zip : 95358-6411
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 5151 N 9TH AVE
Second Line :
City : PENSACOLA
State : FL
Zip : 32504-8721
Country : US
Telephone Number : 850-416-7710
Fax Number : 850-416-7677
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/23/2006
Last Update Date : 05/18/2026

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