Provider Demographics
NPI:1467439893
Name:BOUCHARD, MARTHA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 CLOCKTOWER COMMONS
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509
Mailing Address - Country:US
Mailing Address - Phone:845-279-5187
Mailing Address - Fax:845-279-5168
Practice Address - Street 1:111 CLOCKTOWER COMMONS
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:NY
Practice Address - Zip Code:10509
Practice Address - Country:US
Practice Address - Phone:845-279-5187
Practice Address - Fax:845-279-5168
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY160414207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00924727Medicaid
NY31D481Medicare ID - Type Unspecified
31D481Medicare PIN
NY00924727Medicaid