Provider Demographics
NPI:1740233170
Name:BOLDUC, STEPHEN PATRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:PATRICK
Last Name:BOLDUC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2699
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2699
Mailing Address - Country:US
Mailing Address - Phone:850-278-3920
Mailing Address - Fax:850-278-3919
Practice Address - Street 1:23 MACK BAYOU LOOP
Practice Address - Street 2:SUITE 200
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-2606
Practice Address - Country:US
Practice Address - Phone:850-278-3920
Practice Address - Fax:850-278-3919
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME121545208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA324138OtherANTHEM
VA541778786OtherTAX ID #
VA541778786OtherTRICARE
VA600010207OtherCIGNA
VA54953OtherOPTIMUM
VA41040OtherSENTARA OPTIMA
VA4205768OtherAETNA
VA6724396Medicaid
VA254953OtherMAMSI
VAF90108Medicare UPIN