Provider Demographics
NPI:1528168622
Name:BOUFFARD, MARK H IV (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:H
Last Name:BOUFFARD
Suffix:IV
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 1:72650 FRED WARING DR
Mailing Address - Street 2:SUITE 214
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-5006
Mailing Address - Country:US
Mailing Address - Phone:760-776-7999
Mailing Address - Fax:760-776-7994
Practice Address - Street 1:72650 FRED WARING DR
Practice Address - Street 2:SUITE 214
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-5006
Practice Address - Country:US
Practice Address - Phone:760-776-7999
Practice Address - Fax:760-776-7994
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA892062081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00404516OtherMC RAIL ROAD
CA330808867OtherBLUE CROSS GROUP #
CA330808867OtherBLUE CROSS GROUP #
CA330808867OtherBLUE CROSS GROUP #
CAA89206OtherMEDICAL LICENSE