Provider Demographics
NPI:1730138876
Name:BOURGON, DOUGLAS RENE (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:RENE
Last Name:BOURGON
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:FILE 1687
Mailing Address - Street 2:1801 W OLYMPIC BLVD
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91199-1687
Mailing Address - Country:US
Mailing Address - Phone:415-750-5687
Mailing Address - Fax:415-683-5591
Practice Address - Street 1:450 STANYAN ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-1019
Practice Address - Country:US
Practice Address - Phone:415-750-5687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA985247174400000X
CAA852472085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00248458OtherRAILROAD MEDICARE PIN
CA00A852470Medicaid
CA00A852470Medicaid
CA00A852471Medicare PIN