Provider Demographics
NPI:1154308104
Name:BOUCHARD, MAURICE LOUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:MAURICE
Middle Name:LOUIS
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 1:4724 N DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2339
Mailing Address - Country:US
Mailing Address - Phone:850-696-4000
Mailing Address - Fax:850-444-7057
Practice Address - Street 1:4724 N DAVIS HWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2339
Practice Address - Country:US
Practice Address - Phone:850-696-4000
Practice Address - Fax:850-444-7057
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0056671174400000X
FLME56671208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL063492100Medicaid
FLE51915Medicare UPIN
FL10667YMedicare ID - Type Unspecified