Healthcare Provider Details

I. General information

NPI: 1972009868
Provider Name (Legal Business Name): MOURIEL DEYANIRA BOUCHER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2018
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 W SAMPLE RD STE 236
COCONUT CREEK FL
33073-3473
US

IV. Provider business mailing address

4400 W SAMPLE RD STE 236
COCONUT CREEK FL
33073-3473
US

V. Phone/Fax

Practice location:
  • Phone: 561-421-4500
  • Fax: 561-440-3280
Mailing address:
  • Phone: 561-421-4500
  • Fax: 561-440-3280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberOS20011
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: