Provider Demographics
NPI:1972606911
Name:BOURGEOIS, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BOURGEOIS
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 1:157 BATES HILL RD
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:VT
Mailing Address - Zip Code:05829-9620
Mailing Address - Country:US
Mailing Address - Phone:801-766-2707
Mailing Address - Fax:802-766-5194
Practice Address - Street 1:30 EAST ST
Practice Address - Street 2:ORLEANS MEDICAL CLINIC
Practice Address - City:ORLEANS
Practice Address - State:VT
Practice Address - Zip Code:05860
Practice Address - Country:US
Practice Address - Phone:802-754-2220
Practice Address - Fax:802-754-2195
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0007885207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0009333Medicaid
VTBOVT9333Medicare ID - Type Unspecified
VTC13641Medicare UPIN
VT0009333Medicaid