Provider Demographics
NPI:1154372175
Name:BOURGUIGNON, PAUL ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:ROBERT
Last Name:BOURGUIGNON
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 1:50 FAIR HARBOUR PL
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4731
Mailing Address - Country:US
Mailing Address - Phone:860-443-3147
Mailing Address - Fax:860-443-0087
Practice Address - Street 1:50 FAIR HARBOUR PL
Practice Address - Street 2:SUITE 2C
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4731
Practice Address - Country:US
Practice Address - Phone:860-443-3147
Practice Address - Fax:860-443-0087
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0387032086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
2V8005OtherHEALTHNET
CTP3418275OtherOXFORD
CT001387035Medicaid
CT038703OtherCONNECTICARE
CT010038703CT03OtherANTHEM
CT9636760OtherCIGNA
CT020001695Medicare PIN
CTP3418275OtherOXFORD
CT010038703CT03OtherANTHEM