Provider Demographics
NPI:1134209901
Name:BOUCHER, JOSHUA P (OD)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:P
Last Name:BOUCHER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 NW SUNRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64015-3536
Mailing Address - Country:US
Mailing Address - Phone:816-721-8169
Mailing Address - Fax:
Practice Address - Street 1:4027 MILL ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-3008
Practice Address - Country:US
Practice Address - Phone:816-561-1665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005027604152W00000X
KS1735152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO152W00000XOtherOPTOMETRY