Provider Demographics
NPI:1639174675
Name:BOUCHER, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BOUCHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 RIVER NORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401-1803
Mailing Address - Country:US
Mailing Address - Phone:254-968-6051
Mailing Address - Fax:254-968-4204
Practice Address - Street 1:150 RIVER NORTH BLVD
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-1803
Practice Address - Country:US
Practice Address - Phone:254-968-6051
Practice Address - Fax:254-968-4204
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG4848207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123772901Medicaid
TX010016274OtherRAILROAD MEDICARE PROV NO
TX2060508001OtherCIGNA PROVIDER NUMBER
TX72486303OtherUNITED HEALTHCARE PROV NO
TX814765OtherBCBS PROVIDER NUMBER
TX72486303OtherAETNA PROVIDER NUMBER
TX123772901Medicaid
TX2060508001OtherCIGNA PROVIDER NUMBER