Provider Demographics
NPI:1023040656
Name:BOUCHARD, MARK P (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:P
Last Name:BOUCHARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:301C US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:5 BUCKNAM RD
Practice Address - Street 2:SUITE 2C
Practice Address - City:FALMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04105-1392
Practice Address - Country:US
Practice Address - Phone:207-781-1500
Practice Address - Fax:207-781-1507
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD14613207QS0010X, 208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME254100099Medicaid
MEMM709902Medicare PIN
G62930Medicare UPIN
MEMM7099Medicare PIN
MEMM709904Medicare PIN
ME254100099Medicaid
MEMM709903Medicare PIN