Provider Demographics
NPI:1003131871
Name:BOUCHIE, SAMANTHA DAWN (MD)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:DAWN
Last Name:BOUCHIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6626 E. 75TH STREET
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:317-621-6333
Mailing Address - Fax:317-621-6310
Practice Address - Street 1:9669 E 146TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-5005
Practice Address - Country:US
Practice Address - Phone:317-621-6300
Practice Address - Fax:317-621-6310
Is Sole Proprietor?:No
Enumeration Date:2010-04-05
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN01072482A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201117770Medicaid
IN266180278Medicare PIN