Provider Demographics
NPI:1316392517
Name:BOUCHARD, MARK DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DANIEL
Last Name:BOUCHARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:751 NE BLAKELY DR STE 5010
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98029-6201
Practice Address - Country:US
Practice Address - Phone:425-394-0700
Practice Address - Fax:425-394-0757
Is Sole Proprietor?:No
Enumeration Date:2016-04-26
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD61046264208000000X
NY300476208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1316392517Medicaid