Provider Demographics
NPI:1992869523
Name:BOUCHER, KEVIN E (DO)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:E
Last Name:BOUCHER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CLINIC RD
Mailing Address - Street 2:
Mailing Address - City:ABINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06230-2005
Mailing Address - Country:US
Mailing Address - Phone:860-974-0529
Mailing Address - Fax:860-974-1029
Practice Address - Street 1:5 CLINIC RD
Practice Address - Street 2:
Practice Address - City:ABINGTON
Practice Address - State:CT
Practice Address - Zip Code:06230-2005
Practice Address - Country:US
Practice Address - Phone:860-974-0529
Practice Address - Fax:860-974-1029
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000211207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4476899OtherAETNA
CT1770258-003OtherCIGNA
CTWIP019OtherOXFORD
CT040000211CT-04OtherANTHEM BCBS
CT051180OtherHEALTHNET
CT001002112Medicaid
CT051180OtherHEALTHNET
CT1770258-003OtherCIGNA