Provider Demographics
NPI:1275569352
Name:BOUCHARD, LINDA J (MD)
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:J
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-4720
Mailing Address - Country:US
Mailing Address - Phone:209-860-4393
Mailing Address - Fax:209-650-0684
Practice Address - Street 1:520 E CENTER ST
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4720
Practice Address - Country:US
Practice Address - Phone:209-860-4393
Practice Address - Fax:209-650-0684
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG58369207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G58369Medicaid
CA1386636165OtherGROUP NPI
CA1386636165OtherGROUP NPI
CAZZZ14503ZMedicare PIN
CA68-0277719OtherTAX ID NUMBER