Provider Demographics
NPI:1417962994
Name:BOUGH, EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:BOUGH
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 1:2490 HOSPITAL DR STE 311
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-4126
Mailing Address - Country:US
Mailing Address - Phone:650-962-4690
Mailing Address - Fax:650-962-4694
Practice Address - Street 1:2490 HOSPITAL DR, STE311
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-4122
Practice Address - Country:US
Practice Address - Phone:650-962-4690
Practice Address - Fax:650-962-4694
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG58752207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0098530Medicaid
CAGR0098530Medicaid
CAZZZ86934ZMedicare ID - Type Unspecified