Provider Demographics
NPI:1184604928
Name:BOURQUE, LORI (OPTOMETRIST)
Entity type:Individual
Prefix:DR
First Name:LORI
Middle Name:
Last Name:BOURQUE
Suffix:
Gender:F
Credentials:OPTOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6446 LBJ FWY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-6407
Mailing Address - Country:US
Mailing Address - Phone:972-960-2020
Mailing Address - Fax:972-960-2063
Practice Address - Street 1:6446 LBJ FWY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-6407
Practice Address - Country:US
Practice Address - Phone:972-960-2020
Practice Address - Fax:972-960-2063
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5376T152W00000X
LA1234152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX80502QOtherBCBS
TX80502QMedicare PIN
TXU67717Medicare UPIN