Provider Demographics
NPI:1073593240
Name:BOURGET, JUDY LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:JUDY
Middle Name:LYNN
Last Name:BOURGET
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:34052 LA PLZ
Mailing Address - Street 2:SUITE 104
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-2587
Mailing Address - Country:US
Mailing Address - Phone:949-429-8760
Mailing Address - Fax:949-429-6909
Practice Address - Street 1:34052 LA PLZ
Practice Address - Street 2:SUITE 104
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629-2587
Practice Address - Country:US
Practice Address - Phone:949-429-8760
Practice Address - Fax:949-429-6909
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-22
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG72076208D00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG96136Medicare UPIN