Provider Demographics
NPI:1952393084
Name:BOURQUE, DANIEL R (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:R
Last Name:BOURQUE
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 1:435 HEYMANN BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2616
Mailing Address - Country:US
Mailing Address - Phone:337-234-3344
Mailing Address - Fax:337-234-3352
Practice Address - Street 1:435 HEYMANN BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2616
Practice Address - Country:US
Practice Address - Phone:337-234-3344
Practice Address - Fax:337-234-3352
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2023-06-20
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-04-18
Provider Licenses
StateLicense IDTaxonomies
LA016161207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1952383084OtherINDIVIDUAL NPI
LA1659688489OtherGROUP NPI
LA1345580Medicaid
LA5L938DQ00OtherINDIVIDUAL PTAN
LA5DQ00OtherGROUP PTAN
5L938Medicare PIN
LA1345580Medicaid