Healthcare Provider Details

I. General information

NPI: 1558056721
Provider Name (Legal Business Name): MOLLY O'BRIEN-BOUCHARD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2023
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4939 BRITTONFIELD PKWY
EAST SYRACUSE NY
13057-9208
US

IV. Provider business mailing address

4939 BRITTONFIELD PKWY
EAST SYRACUSE NY
13057-9208
US

V. Phone/Fax

Practice location:
  • Phone: 315-463-1600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number344090
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: