Provider Demographics
NPI:1023447513
Name:BOURQUE, ROBERT GERALD (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:GERALD
Last Name:BOURQUE
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 1:4780 S LAKE DR
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-5914
Mailing Address - Country:US
Mailing Address - Phone:561-731-4311
Mailing Address - Fax:
Practice Address - Street 1:4780 S LAKE DR
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33436-5914
Practice Address - Country:US
Practice Address - Phone:561-731-4311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17602207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology