Provider Demographics
NPI:1376743427
Name:BODIN, MICHAEL SHANE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SHANE
Last Name:BODIN
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 1:2647 S SAINT ELIZABETH BLVD
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-5021
Mailing Address - Country:US
Mailing Address - Phone:225-647-8511
Mailing Address - Fax:225-644-5213
Practice Address - Street 1:2647 S SAINT ELIZABETH BLVD STE 219
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-5020
Practice Address - Country:US
Practice Address - Phone:225-765-5500
Practice Address - Fax:225-743-2620
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200969207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1238341Medicaid
LA1238341Medicaid