Provider Demographics
NPI:1447571864
Name:BOUCHER-CORNELIO, CATHERINE GISELE (DO)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:GISELE
Last Name:BOUCHER-CORNELIO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 INDUSTRIAL PARK RD
Mailing Address - Street 2:
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072-1804
Mailing Address - Country:US
Mailing Address - Phone:207-283-8800
Mailing Address - Fax:207-294-3561
Practice Address - Street 1:13 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072
Practice Address - Country:US
Practice Address - Phone:207-294-3561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-21
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT013764207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME003446601Medicare UPIN