Provider Demographics
NPI:1568451193
Name:BOURQUARD, WILLIAM SULLIVAN (MD)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:SULLIVAN
Last Name:BOURQUARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:6148 N DISCOVERY WAY
Mailing Address - Street 2:STE 100
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-0201
Mailing Address - Country:US
Mailing Address - Phone:208-322-5437
Mailing Address - Fax:208-322-4638
Practice Address - Street 1:6148 N DISCOVERY WAY
Practice Address - Street 2:STE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-0201
Practice Address - Country:US
Practice Address - Phone:208-322-5437
Practice Address - Fax:208-322-4638
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-17
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM5223208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003597000Medicaid
ID000010006127OtherBLUE SHIELD
ID52233OtherBLUE CROSS
ID003597000Medicaid