Provider Demographics
NPI:1356795413
Name:BOUCHARD, LAUREN THERESE JOSIAH
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:THERESE JOSIAH
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22344 LAKE SHORE BLVD
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44123-1717
Practice Address - Country:US
Practice Address - Phone:216-512-9533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-14
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.140012207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology