Healthcare Provider Details

I. General information

NPI: 1134128929
Provider Name (Legal Business Name): FRANCIS H BOUDREAU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BRULE ST
FORT KNOX KY
40121-6100
US

IV. Provider business mailing address

1459 5TH AVE
FORT KNOX KY
40121-2237
US

V. Phone/Fax

Practice location:
  • Phone: 502-626-9834
  • Fax:
Mailing address:
  • Phone: 386-697-5383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME82841
License Number StateFL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier261890700
Identifier TypeMEDICAID
Identifier StateFL
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: