Provider Demographics
NPI:1083616940
Name:BOURGEOIS, ROBERT SIDNEY (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:SIDNEY
Last Name:BOURGEOIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12915 KEDLESTON CIRCLE
Mailing Address - Street 2:
Mailing Address - City:FT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912
Mailing Address - Country:US
Mailing Address - Phone:239-826-3578
Mailing Address - Fax:239-931-6125
Practice Address - Street 1:3033 WINKLER EXTENSION
Practice Address - Street 2:
Practice Address - City:FT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916
Practice Address - Country:US
Practice Address - Phone:239-939-3939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME34882207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL373863900Medicaid