Provider Demographics
NPI:1003004532
Name:BOUCHARD, DONALD FRANCIS
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:FRANCIS
Last Name:BOUCHARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 WATERHOUSE LN
Mailing Address - Street 2:GOLDSTAR MEDICAL SERVICES, INC.
Mailing Address - City:CHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06412
Mailing Address - Country:US
Mailing Address - Phone:860-526-4333
Mailing Address - Fax:860-526-4333
Practice Address - Street 1:17 WATERHOUSE LN
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:CT
Practice Address - Zip Code:06412-1267
Practice Address - Country:US
Practice Address - Phone:860-526-4333
Practice Address - Fax:860-526-4333
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTGO376254OtherBLUE CROSS/SHIELD MA
CT12DME0363CT02OtherANTHEM BLUE CROSS CT
CTGO376254OtherBLUE CROSS/SHIELD MA