Provider Demographics
NPI:1114088101
Name:BOUGHN, RICHARD C (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:C
Last Name:BOUGHN
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 1:613 N 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:STAYTON
Mailing Address - State:OR
Mailing Address - Zip Code:97383-1704
Mailing Address - Country:US
Mailing Address - Phone:503-769-7771
Mailing Address - Fax:503-769-4630
Practice Address - Street 1:613 N 1ST AVE
Practice Address - Street 2:
Practice Address - City:STAYTON
Practice Address - State:OR
Practice Address - Zip Code:97383-1704
Practice Address - Country:US
Practice Address - Phone:503-769-7771
Practice Address - Fax:503-769-4630
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10079207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1114088101Medicaid
OR072678Medicaid
C92253Medicare UPIN