Provider Demographics
NPI:1043388788
Name:BOUFFARD, JOSE ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ANTONIO
Last Name:BOUFFARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:J
Other - Middle Name:ANTONIO
Other - Last Name:BOUFFARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:261 MACK AVE
Mailing Address - Street 2:ROOM 215
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2417
Mailing Address - Country:US
Mailing Address - Phone:313-966-2539
Mailing Address - Fax:313-993-2630
Practice Address - Street 1:261 MACK AVE
Practice Address - Street 2:ROOM 215
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2417
Practice Address - Country:US
Practice Address - Phone:313-966-2539
Practice Address - Fax:313-993-2630
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044748207UN0902X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIJB044748OtherSTATE LICENSURE
A77315Medicare UPIN