Provider Demographics
NPI:1487644878
Name:BOUSEL, DON (MD)
Entity Type:Individual
Prefix:DR
First Name:DON
Middle Name:
Last Name:BOUSEL
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 1:2300 BRIGHT LEAF WAY
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3470
Mailing Address - Country:US
Mailing Address - Phone:410-358-8232
Mailing Address - Fax:
Practice Address - Street 1:2411 W BELVEDERE AVE
Practice Address - Street 2:STE 201
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5229
Practice Address - Country:US
Practice Address - Phone:410-542-5116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD36353207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD528101600Medicaid
MD622QMedicare ID - Type Unspecified
MD528101600Medicaid