Healthcare Provider Details

I. General information

NPI: 1164115549
Provider Name (Legal Business Name): DANIEL ELKINS BOUCHER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2023
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15230 LAKESHORE DR
CLEARLAKE CA
95422-8107
US

IV. Provider business mailing address

15230 LAKESHORE DR
CLEARLAKE CA
95422-8107
US

V. Phone/Fax

Practice location:
  • Phone: 707-995-4500
  • Fax: 707-994-2401
Mailing address:
  • Phone: 707-995-4500
  • Fax: 707-994-2401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA208143
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: