Provider Demographics
NPI:1942246418
Name:BOUCHARD, TODD S (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:S
Last Name:BOUCHARD
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 1:3600 LIND AVE SW
Mailing Address - Street 2:STE 100
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-4934
Mailing Address - Country:US
Mailing Address - Phone:425-656-5412
Mailing Address - Fax:425-656-5423
Practice Address - Street 1:16850 SE 272ND ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:WA
Practice Address - Zip Code:98042-4931
Practice Address - Country:US
Practice Address - Phone:253-395-1960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00031935207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1094622Medicaid
WAF95380Medicare UPIN
WAAB13279Medicare ID - Type Unspecified