Healthcare Provider Details

I. General information

NPI: 1609181668
Provider Name (Legal Business Name): JUDY L BOURGET MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2010
Last Update Date: 08/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34052 LA PLZ STE 104
DANA POINT CA
92629-2587
US

IV. Provider business mailing address

34052 LA PLZ STE 104
DANA POINT CA
92629-2587
US

V. Phone/Fax

Practice location:
  • Phone: 949-429-8760
  • Fax: 949-429-6909
Mailing address:
  • Phone: 949-429-8760
  • Fax: 949-429-6909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG72076
License Number StateCA

VIII. Authorized Official

Name: DR. JUDY L BOURGET
Title or Position: OWNER
Credential: MD
Phone: 949-429-8760