Provider Demographics
NPI:1154612117
Name:BOUCEK, DANA
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:BOUCEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 MARKET ST UNIT 1713
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-5914
Mailing Address - Country:US
Mailing Address - Phone:303-746-7692
Mailing Address - Fax:
Practice Address - Street 1:100 NORTH MARIO CAPECCHI DR.
Practice Address - Street 2:PRIMARY CHILDREN'S
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113
Practice Address - Country:US
Practice Address - Phone:801-662-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-26
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4607222080P0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program