Provider Demographics
NPI:1750472213
Name:BOUCH, BRIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:BOUCH
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 1:1410 SKILLMAN LN
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-1249
Mailing Address - Country:US
Mailing Address - Phone:707-765-0259
Mailing Address - Fax:
Practice Address - Street 1:1410 SKILLMAN LN
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-1249
Practice Address - Country:US
Practice Address - Phone:707-696-7427
Practice Address - Fax:707-615-5775
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35969207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine