Provider Demographics
NPI:1407849029
Name:BOURGAULT, STEPHEN JOHN (OD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:JOHN
Last Name:BOURGAULT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 FOX ST
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-3235
Mailing Address - Country:US
Mailing Address - Phone:978-342-7147
Mailing Address - Fax:978-345-3567
Practice Address - Street 1:61 FOX ST
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-3235
Practice Address - Country:US
Practice Address - Phone:978-342-7147
Practice Address - Fax:978-345-3567
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2887152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9783814Medicaid
MA9783814Medicaid
MASTW21010Medicare ID - Type Unspecified