Healthcare Provider Details

I. General information

NPI: 1114088101
Provider Name (Legal Business Name): RICHARD C BOUGHN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 06/12/2020
Certification Date: 06/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 N 1ST AVE
STAYTON OR
97383-1704
US

IV. Provider business mailing address

613 N 1ST AVE
STAYTON OR
97383-1704
US

V. Phone/Fax

Practice location:
  • Phone: 503-769-7771
  • Fax: 503-769-4630
Mailing address:
  • Phone: 503-769-7771
  • Fax: 503-769-4630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD10079
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: