Provider Demographics
NPI:1578641601
Name:BOUVIER, LUCIENNE SIMONE (MD)
Entity Type:Individual
Prefix:
First Name:LUCIENNE
Middle Name:SIMONE
Last Name:BOUVIER
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 1:85 SIERRA PARK RD
Mailing Address - Street 2:
Mailing Address - City:MAMMOTH LAKES
Mailing Address - State:CA
Mailing Address - Zip Code:93546-2073
Mailing Address - Country:US
Mailing Address - Phone:760-932-3311
Mailing Address - Fax:
Practice Address - Street 1:85 SIERRA PARK RD
Practice Address - Street 2:
Practice Address - City:MAMMOTH LAKES
Practice Address - State:CA
Practice Address - Zip Code:93546-2073
Practice Address - Country:US
Practice Address - Phone:760-934-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79050207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G790500Medicaid
G30510Medicare UPIN
00G790500Medicare ID - Type Unspecified