Provider Demographics
NPI:1427038157
Name:BOUCHARD, LAWRENCE F (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:F
Last Name:BOUCHARD
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 1:676 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44311-1059
Mailing Address - Country:US
Mailing Address - Phone:330-344-4000
Mailing Address - Fax:330-253-2349
Practice Address - Street 1:676 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44311-1059
Practice Address - Country:US
Practice Address - Phone:330-344-4000
Practice Address - Fax:330-253-2349
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-6863207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9338635OtherMEDICARE GROUP NUMBER
OH2551671OtherMEDICAID GROUP #
OH1841239274OtherMEDICARE/MEDICAID GROUP NPI #
OH1548207111OtherNPI GROUP NUMBER
OH0170032Medicaid
OH0645343Medicare PIN
OH1548207111OtherNPI GROUP NUMBER
OH1232120003Medicare NSC