Provider Demographics
NPI:1427254846
Name:BOURQUE, DANIEL L (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:L
Last Name:BOURQUE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:960 MASSACHUSETTS AVENUE
Mailing Address - Street 2:FL 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:725 ALBANY ST, STE 9B & C
Practice Address - Street 2:SHAPIRO BLDG
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2526
Practice Address - Country:US
Practice Address - Phone:617-414-4290
Practice Address - Fax:617-414-4285
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA243941207RI0200X, 207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1100907782AMedicaid