Healthcare Provider Details

I. General information

NPI: 1245285824
Provider Name (Legal Business Name): SHANNON CHRISTOPHER BOUDREAUX MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: SHANNON CHRISTOPHER BOUDREAUX MD

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BUBBA WATSON DRIVE
PENSACOLA FL
32504-8721
US

IV. Provider business mailing address

1601 CUMMINS DR STE D
MODESTO CA
95358-6411
US

V. Phone/Fax

Practice location:
  • Phone: 850-416-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME95353
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME95353
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: