MEDICARE: DR. MICHAEL SHANE BODIN 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
1	207Q00000X	Family Medicine Physician	200969	LA

Other Identifiers

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

General Provider Information

NPI Number	:	1376743427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL SHANE BODIN MD

Provider Business Mailing Address
First Line	:	2647 S SAINT ELIZABETH BLVD
Second Line	:
City	:	GONZALES
State	:	LA
Zip	:	70737-5021
Country	:	US
Telephone Number	:	225-647-8511
Fax Number	:	225-644-5213

Provider Business Practice Location Address
First Line	:	2647 S SAINT ELIZABETH BLVD STE 219
Second Line	:
City	:	GONZALES
State	:	LA
Zip	:	70737-5020
Country	:	US
Telephone Number	:	225-765-5500
Fax Number	:	225-743-2620

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2007
Last Update Date	:	01/14/2021

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