Provider Demographics
NPI:1932181625
Name:BOU-GAUTHIER, SALVADOR ANGEL (MD)
Entity Type:Individual
Prefix:
First Name:SALVADOR
Middle Name:ANGEL
Last Name:BOU-GAUTHIER
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 1:1507 W REYNOLDS ST STE A
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33563-4702
Mailing Address - Country:US
Mailing Address - Phone:813-719-3716
Mailing Address - Fax:813-759-2487
Practice Address - Street 1:1507 W REYNOLDS ST STE A
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-4702
Practice Address - Country:US
Practice Address - Phone:813-719-3716
Practice Address - Fax:813-759-2487
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64556208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL374065000Medicaid
ME64556OtherME
23602OtherBCBS
ME64556OtherME