Blake William Boudreaux, MD

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

License

ME173977 Issued in FL

Practice address

103 Solana Rd Ste B
Ponte Vedra Beach, FL 32082-2231

Phone

(904) 273-2717

NPI assigned

Apr 5, 2020

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in FL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Dermatology

Education

Louisiana State University School of Medicine in Shreveport, 2021

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Beaches Dermatology, P.a.Group PAC ID 9133190549, 15 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Baptist Health Medical Center - Jacksonville Hospital, Jacksonville, FL, CCN 100088

Procedures performed for Medicare patients

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: bboudreaux@beachesderm.emadirect.md

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Beaches Dermatology, P.a.

  • Specialist
  • Ponte Vedra Beach, FL
  • NPI 1780627521

  Dermatology

  Medicare reassignment Care Compare group NPD

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Southern Baptist Hospital of Florida Inc

  • General Acute Care Hospital
  • Jacksonville, FL
  • NPI 1578620449
  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1586044800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1782950400000",
    "number": "1689203341",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "103 SOLANA RD STE B",
            "city": "PONTE VEDRA BEACH",
            "state": "FL",
            "postal_code": "320822231",
            "telephone_number": "904-273-2717",
            "fax_number": "904-273-0410"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "103 SOLANA RD STE B",
            "city": "PONTE VEDRA BEACH",
            "state": "FL",
            "postal_code": "320822231",
            "telephone_number": "904-273-2717"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "614 E Twincourt Trl",
            "address_purpose": "LOCATION",
            "city": "St Augustine",
            "state": "FL",
            "postal_code": "320959090",
            "country_code": "US",
            "telephone_number": "904-808-7107",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "791 Amelia Island Pkwy",
            "address_purpose": "LOCATION",
            "city": "Fernandina Beach",
            "state": "FL",
            "postal_code": "320349126",
            "country_code": "US",
            "telephone_number": "904-261-7500",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "BOUDREAUX",
        "first_name": "BLAKE",
        "middle_name": "WILLIAM",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2020-04-05",
        "last_updated": "2026-07-02",
        "certification_date": "2026-07-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "FL",
            "license": "ME173977",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Dermatology Physician in Ponte Vedra Beach, FL
• Providers in Ponte Vedra Beach, FL by specialty
• Dermatology Physician in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 2, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.