Healthcare Provider Details

I. General information

NPI: 1952393084
Provider Name (Legal Business Name): DANIEL R BOURQUE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date: 03/22/2006
Reactivation Date: 04/18/2006

III. Provider practice location address

435 HEYMANN BLVD
LAFAYETTE LA
70503-2616
US

IV. Provider business mailing address

435 HEYMANN BLVD
LAFAYETTE LA
70503-2616
US

V. Phone/Fax

Practice location:
  • Phone: 337-234-3344
  • Fax: 337-234-3352
Mailing address:
  • Phone: 337-234-3344
  • Fax: 337-234-3352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number016161
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: