Healthcare Provider Details

I. General information

NPI: 1154372175
Provider Name (Legal Business Name): PAUL ROBERT BOURGUIGNON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 05/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 FAIR HARBOUR PL SUITE 2C
NEW LONDON CT
06320-4731
US

IV. Provider business mailing address

50 FAIR HARBOUR PL SUITE 2C
NEW LONDON CT
06320-4731
US

V. Phone/Fax

Practice location:
  • Phone: 860-443-3147
  • Fax: 860-443-0087
Mailing address:
  • Phone: 860-443-3147
  • Fax: 860-443-0087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number038703
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: