Provider Demographics
NPI:1508850504
Name:BOUCHER, DANIELLE A (MD)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:A
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:A
Other - Last Name:LINCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-242-8790
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:1220 N HIGHWAY A1A STE 147
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-2858
Practice Address - Country:US
Practice Address - Phone:321-242-8790
Practice Address - Fax:321-242-1541
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82139207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2599246OtherAETNA
FLP01164038OtherRR MEDICARE
FL51172OtherFLORIDA BLUE (BCBS OF FL)
FL5481530001OtherCIGNA
FL51172OtherFLORIDA BLUE (BCBS OF FL)
FL51172YMedicare PIN