Provider Demographics
NPI:1457494460
Name:BOUQUOT, JERRY E (DDS)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:E
Last Name:BOUQUOT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6516 MD ANDERSON BLVD
Mailing Address - Street 2:RM #3.094F
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030
Mailing Address - Country:US
Mailing Address - Phone:866-446-4936
Mailing Address - Fax:713-450-3988
Practice Address - Street 1:6516 MD ANDERSON BLVD
Practice Address - Street 2:RM #3.094F
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030
Practice Address - Country:US
Practice Address - Phone:866-446-4936
Practice Address - Fax:713-450-3988
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22003207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00305690OtherMEDICARE RAILROAD CARRIER
TX89D241OtherBLUE CROSS BLUE SHIELD
TX8D1709Medicare ID - Type Unspecified
TX89D241OtherBLUE CROSS BLUE SHIELD