Provider Demographics
NPI:1093895765
Name:BOUCHARD, EDWARD W (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:W
Last Name:BOUCHARD
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:PO BOX 47509
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-0113
Mailing Address - Country:US
Mailing Address - Phone:813-899-6226
Mailing Address - Fax:813-985-8006
Practice Address - Street 1:6983 E FOWLER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33617-1714
Practice Address - Country:US
Practice Address - Phone:813-899-6226
Practice Address - Fax:813-985-8006
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME892612085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269312700Medicaid
FL269312700Medicaid
FLU2345ZMedicare ID - Type Unspecified