Provider Demographics
NPI:1235167677
Name:BOUGHER, VIRGINIA (OD)
Entity Type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:
Last Name:BOUGHER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 DISCOVERY BLVD
Mailing Address - Street 2:SUITE 111 BLDG. 1
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-2295
Mailing Address - Country:US
Mailing Address - Phone:512-260-2100
Mailing Address - Fax:512-260-2102
Practice Address - Street 1:715 DISCOVERY BLVD
Practice Address - Street 2:SUITE 111 BLDG. 1
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-2295
Practice Address - Country:US
Practice Address - Phone:512-260-2100
Practice Address - Fax:512-260-2102
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2010-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2225TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U13985Medicare UPIN
TX8C2427Medicare PIN