Provider Demographics
NPI:1245285824
Name:BOUDREAUX, SHANNON CHRISTOPHER (MD)
Entity type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:CHRISTOPHER
Last Name:BOUDREAUX
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:SHANNON
Other - Middle Name:CHRISTOPHER
Other - Last Name:BOUDREAUX
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:14516 LAKE TOWN DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810
Mailing Address - Country:US
Mailing Address - Phone:850-261-9939
Mailing Address - Fax:
Practice Address - Street 1:5151 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8721
Practice Address - Country:US
Practice Address - Phone:850-416-7710
Practice Address - Fax:850-416-7677
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME95353207P00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics