Provider Demographics
NPI:1376548180
Name:BOURDON, LYNN (MD)
Entity Type:Individual
Prefix:MR
First Name:LYNN
Middle Name:
Last Name:BOURDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 MOCKINGBIRD LN
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-3556
Mailing Address - Country:US
Mailing Address - Phone:903-236-3323
Mailing Address - Fax:903-236-3734
Practice Address - Street 1:200 W SCURRY ST STE A
Practice Address - Street 2:
Practice Address - City:DAINGERFIELD
Practice Address - State:TX
Practice Address - Zip Code:75638-1634
Practice Address - Country:US
Practice Address - Phone:903-645-2044
Practice Address - Fax:903-645-2270
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXC8905207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX135593511Medicaid
TX135593511Medicaid
TXB21419Medicare UPIN