Provider Demographics
NPI:1659638575
Name:BOURGON, ADAM LABREE (DO)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:LABREE
Last Name:BOURGON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633D MEDICAL GROUP
Mailing Address - Street 2:77 NEALY AVE
Mailing Address - City:JOINT BASE LANGLEY-EUSTIS
Mailing Address - State:VA
Mailing Address - Zip Code:23665-2040
Mailing Address - Country:US
Mailing Address - Phone:757-225-4263
Mailing Address - Fax:
Practice Address - Street 1:633D MEDICAL GROUP
Practice Address - Street 2:77 NEALY AVE
Practice Address - City:JOINT BASE LANGLEY-EUSTIS
Practice Address - State:VA
Practice Address - Zip Code:23665-2040
Practice Address - Country:US
Practice Address - Phone:757-764-6950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-17
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI74912208600000X
VA0102205429208600000X
390200000X
IN02004369A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program