Provider Demographics
NPI:1609181668
Name:JUDY L BOURGET MD INC
Entity Type:Organization
Organization Name:JUDY L BOURGET MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOURGET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-429-8760
Mailing Address - Street 1:34052 LA PLZ
Mailing Address - Street 2:STE 104
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-2587
Mailing Address - Country:US
Mailing Address - Phone:949-429-8760
Mailing Address - Fax:949-429-6909
Practice Address - Street 1:34052 LA PLZ
Practice Address - Street 2:STE 104
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629-2587
Practice Address - Country:US
Practice Address - Phone:949-429-8760
Practice Address - Fax:949-429-6909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG72076208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG96136Medicare UPIN