Healthcare Provider Details

I. General information

NPI: 1750876991
Provider Name (Legal Business Name): BRYAN THOMAS BOURDEAU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2018
Last Update Date: 05/04/2025
Certification Date: 05/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 PARNASSUS AVE
SAN FRANCISCO CA
94143-2206
US

IV. Provider business mailing address

330 BROOKLINE AVE
BOSTON MA
02215-5491
US

V. Phone/Fax

Practice location:
  • Phone: 415-476-1000
  • Fax:
Mailing address:
  • Phone: 617-667-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number276390
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA202521
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number286471
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: