Provider Demographics
NPI:1205060175
Name:BOURQUE, JASON (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:
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 1:120 RUE LOUIS XIV
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-5739
Mailing Address - Country:US
Mailing Address - Phone:337-769-7779
Mailing Address - Fax:
Practice Address - Street 1:120 RUE LOUIS XIV
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-5739
Practice Address - Country:US
Practice Address - Phone:337-769-7779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10033777208800000X
TXQ3854208800000X
LA307858208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology