Provider Demographics
NPI:1205827532
Name:BOUCHER, JEAN-DENIS (MD)
Entity Type:Individual
Prefix:DR
First Name:JEAN-DENIS
Middle Name:
Last Name:BOUCHER
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 3112
Mailing Address - Street 2:
Mailing Address - City:UNIVERSAL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78148-2212
Mailing Address - Country:US
Mailing Address - Phone:210-651-3233
Mailing Address - Fax:210-651-3234
Practice Address - Street 1:11101 TOEPPERWEIN RD
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3143
Practice Address - Country:US
Practice Address - Phone:210-651-3233
Practice Address - Fax:210-651-3234
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-04
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8022207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0043QROtherBC/BS PROVIDER ID
TX4219937OtherBC/BS BLUE LINK I.D.
TX4219937OtherBC/BS BLUE LINK I.D.
TX00690WMedicare PIN