Provider Demographics
NPI:1598710899
Name:BOUGH, IRVIN D JR (MD)
Entity Type:Individual
Prefix:DR
First Name:IRVIN
Middle Name:D
Last Name:BOUGH
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:I
Other - Middle Name:DAVID
Other - Last Name:BOUGH
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:660 WHITE PLAINS RD FL 4
Mailing Address - Street 2:
Mailing Address - City:TARRYTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10591-5139
Mailing Address - Country:US
Mailing Address - Phone:914-984-2546
Mailing Address - Fax:
Practice Address - Street 1:650 FROM RD STE 170
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-3517
Practice Address - Country:US
Practice Address - Phone:201-722-9850
Practice Address - Fax:201-722-9850
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY201905-1207Y00000X
NJ25MA06358300207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJF10475Medicare UPIN
NJ001814NEWMedicare ID - Type Unspecified
NYOX9691Medicare ID - Type Unspecified