Healthcare Provider Details

I. General information

NPI: 1376548180
Provider Name (Legal Business Name): LYNN BOURDON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 05/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W SCURRY ST STE A
DAINGERFIELD TX
75638-1634
US

IV. Provider business mailing address

1100 MOCKINGBIRD LN
LONGVIEW TX
75601-3556
US

V. Phone/Fax

Practice location:
  • Phone: 903-645-2044
  • Fax: 903-645-2270
Mailing address:
  • Phone: 903-236-3323
  • Fax: 903-236-3734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC8905
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: