Healthcare Provider Details

I. General information

NPI: 1306923313
Provider Name (Legal Business Name): DONNIE D BOUCHARD DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 02/25/2021
Certification Date: 02/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63559 60TH AVE
HARTFORD MI
49057-8662
US

IV. Provider business mailing address

4408 S WESTNEDGE AVE
KALAMAZOO MI
49008-3210
US

V. Phone/Fax

Practice location:
  • Phone: 269-270-9332
  • Fax: 269-312-8283
Mailing address:
  • Phone: 269-270-9332
  • Fax: 269-312-8283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5101011443
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: