Provider Demographics
NPI:1720495278
Name:BOUCHEZ, JEROME
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:BOUCHEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 REGENCY PKWY
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-3791
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:310 REGENCY PKWY
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-3791
Practice Address - Country:US
Practice Address - Phone:302-543-5780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1417152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist