Provider Demographics
NPI:1295742740
Name:BOUCHARD, ERIC S (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:S
Last Name:BOUCHARD
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 1:1300 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4646
Mailing Address - Country:US
Mailing Address - Phone:850-216-0100
Mailing Address - Fax:850-201-4873
Practice Address - Street 1:1300 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4646
Practice Address - Country:US
Practice Address - Phone:850-216-0100
Practice Address - Fax:850-201-4873
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87495207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL267896900Medicaid
GA154344087AMedicaid
GA154344087AMedicaid
FL267896900Medicaid