Provider Demographics
NPI:1275521270
Name:BOUCHARD, JAMES L (DPM)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:L
Last Name:BOUCHARD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 491658
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30049-0028
Mailing Address - Country:US
Mailing Address - Phone:770-255-0434
Mailing Address - Fax:770-255-0433
Practice Address - Street 1:15 HURRICANE SHOALS RD NE
Practice Address - Street 2:SUITE A
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4454
Practice Address - Country:US
Practice Address - Phone:770-255-0434
Practice Address - Fax:770-255-0433
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000418213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00118148FMedicaid
GA00118148FMedicaid