Provider Demographics
NPI:1306923313
Name:BOUCHARD, DONNIE D (DO)
Entity type:Individual
Prefix:
First Name:DONNIE
Middle Name:D
Last Name:BOUCHARD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4408 S WESTNEDGE AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-3210
Mailing Address - Country:US
Mailing Address - Phone:269-270-9332
Mailing Address - Fax:269-312-8283
Practice Address - Street 1:63559 60TH AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:MI
Practice Address - Zip Code:49057-8662
Practice Address - Country:US
Practice Address - Phone:269-270-9332
Practice Address - Fax:269-312-8283
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011443208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
F81596Medicare UPIN