Provider Demographics
NPI:1750677605
Name:BOUCHARD, MARC ANTHONY (DO)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:ANTHONY
Last Name:BOUCHARD
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 1:2110 GALLOWS RD STE D
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3962
Mailing Address - Country:US
Mailing Address - Phone:603-858-0047
Mailing Address - Fax:331-204-0820
Practice Address - Street 1:2110 GALLOWS RD STE D
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3962
Practice Address - Country:US
Practice Address - Phone:703-592-4600
Practice Address - Fax:331-204-0820
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2022-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP609421312084P0800X
VA01022033462084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty