Healthcare Provider Details

I. General information

NPI: 1972573889
Provider Name (Legal Business Name): JAMES P BOUQUET O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 07/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 W PENN AVE
CLEONA PA
17042-3230
US

IV. Provider business mailing address

233 W PENN AVE
CLEONA PA
17042-3230
US

V. Phone/Fax

Practice location:
  • Phone: 717-272-0581
  • Fax: 717-274-5889
Mailing address:
  • Phone: 717-272-0581
  • Fax: 717-274-5889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG000036
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: