Provider Demographics
NPI:1013986801
Name:BOUCHER, CHARLES ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ALLEN
Last Name:BOUCHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:8 HAWTHORNE PL
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2335
Mailing Address - Country:US
Mailing Address - Phone:617-726-8511
Mailing Address - Fax:617-726-9839
Practice Address - Street 1:8 HAWTHORNE PL
Practice Address - Street 2:SUITE 110
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2335
Practice Address - Country:US
Practice Address - Phone:617-726-8511
Practice Address - Fax:617-726-9839
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-15
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA36588207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2064227Medicaid
MA705823OtherTUFTS HEALTH PLAN
MAM09801OtherBCBS MA
A67358Medicare UPIN
MAM09801Medicare ID - Type Unspecified