Healthcare Provider Details

I. General information

NPI: 1356082168
Provider Name (Legal Business Name): DR. CHRISTOPHER LEE BOUDREAU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13837 CIRCA CROSSING DR
LITHIA FL
33547-4382
US

IV. Provider business mailing address

13837 CIRCA CROSSING DR
LITHIA FL
33547-4382
US

V. Phone/Fax

Practice location:
  • Phone: 813-684-2663
  • Fax: 813-658-6222
Mailing address:
  • Phone: 813-684-2663
  • Fax: 813-658-6222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number38351
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: