Provider Demographics
NPI:1427054907
Name:BOURQUE, DOUGLAS MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:MICHAEL
Last Name:BOURQUE
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 1:3509 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224
Mailing Address - Country:US
Mailing Address - Phone:410-558-4900
Mailing Address - Fax:410-522-1475
Practice Address - Street 1:3509 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224
Practice Address - Country:US
Practice Address - Phone:410-558-4900
Practice Address - Fax:410-522-1475
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD030359207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
S7321089Medicare ID - Type Unspecified
C49376Medicare UPIN