Provider Demographics
NPI:1518945401
Name:BOUCHER, TINA ANNE (DPM)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:ANNE
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-4301
Mailing Address - Country:US
Mailing Address - Phone:203-238-3668
Mailing Address - Fax:203-238-3670
Practice Address - Street 1:807 BROAD ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-4301
Practice Address - Country:US
Practice Address - Phone:203-238-3668
Practice Address - Fax:203-238-3670
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0000805213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTV06988Medicare UPIN
CT5939420001Medicare NSC