Healthcare Provider Details

I. General information

NPI: 1770608721
Provider Name (Legal Business Name): ROBERT BRADLEY BOUGHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1734 YORK RD
LUTHERVILLE MD
21093-5606
US

IV. Provider business mailing address

11121 YORK RD
HUNT VALLEY MD
21030-2006
US

V. Phone/Fax

Practice location:
  • Phone: 410-252-2273
  • Fax:
Mailing address:
  • Phone: 410-628-0026
  • Fax: 410-667-6834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0069537
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0069537
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: