Provider Demographics
NPI:1720197361
Name:BOURGOIN, MICHAEL PAUL (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PAUL
Last Name:BOURGOIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1835 NEWPORT BLVD
Mailing Address - Street 2:SUITE A-111
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-5031
Mailing Address - Country:US
Mailing Address - Phone:949-646-4949
Mailing Address - Fax:949-646-2533
Practice Address - Street 1:1835 NEWPORT BLVD
Practice Address - Street 2:SUITE A-111
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-5031
Practice Address - Country:US
Practice Address - Phone:949-646-4949
Practice Address - Fax:949-646-2533
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9870T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1548472921OtherGROUP NPI
CA9870TOtherCA OPTOMETRY LICENSE #
CAWOP9870IOtherPPIN
CAWOP9870IOtherPPIN
CA1548472921OtherGROUP NPI