Provider Demographics
NPI:1407870330
Name:BOUSLOUGH, DAVID BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:BRUCE
Last Name:BOUSLOUGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 YORK STREET, CB-2041
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3220
Mailing Address - Country:US
Mailing Address - Phone:203-688-1734
Mailing Address - Fax:203-688-9638
Practice Address - Street 1:365 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320
Practice Address - Country:US
Practice Address - Phone:860-442-0711
Practice Address - Fax:203-688-9638
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ASA96799207P00000X
RIMD11583207P00000X
CT62616207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1407870330OtherNPI
RI7056948Medicaid
MA06222010OtherTUFTS HEALTH PLAN
RI07082010OtherNHPRI
RI12142010OtherTRICARE
RI939025129OtherRI MEDICARE GROUP NUMBER
RI06292010OtherBCBSRI
RI7056948Medicaid
RII21458Medicare UPIN