Provider Demographics
NPI:1770608721
Name:BOUGHAN, ROBERT BRADLEY (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:BRADLEY
Last Name:BOUGHAN
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 1:11121 YORK RD
Mailing Address - Street 2:
Mailing Address - City:HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21030-2006
Mailing Address - Country:US
Mailing Address - Phone:410-628-0026
Mailing Address - Fax:410-667-6834
Practice Address - Street 1:1734 YORK RD
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-5606
Practice Address - Country:US
Practice Address - Phone:410-252-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0069537208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics