Provider Demographics
NPI:1063414134
Name:BOURNE, CECIL M (MD)
Entity type:Individual
Prefix:
First Name:CECIL
Middle Name:M
Last Name:BOURNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 SANTA FE ST
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78404-2338
Mailing Address - Country:US
Mailing Address - Phone:361-884-9900
Mailing Address - Fax:361-884-9903
Practice Address - Street 1:1215 SANTA FE ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-2338
Practice Address - Country:US
Practice Address - Phone:361-884-9900
Practice Address - Fax:361-884-9903
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-02
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD8154207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82N381OtherBCBS
TX110184080OtherMEDICARE RAILROAD
TX00823KOtherBLUE CROSS
TX081210901Medicaid
TX82N381OtherBCBS
TX82780NMedicare PIN