Healthcare Provider Details

I. General information

NPI: 1245419118
Provider Name (Legal Business Name): CECIL M. BOURNE, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2007
Last Update Date: 10/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 S ALAMEDA ST SUITE 306
CORPUS CHRISTI TX
78411-1882
US

IV. Provider business mailing address

3301 S ALAMEDA ST SUITE 306
CORPUS CHRISTI TX
78411-1882
US

V. Phone/Fax

Practice location:
  • Phone: 361-852-4200
  • Fax: 361-852-5304
Mailing address:
  • Phone: 361-852-4200
  • Fax: 361-852-5304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD8154
License Number StateTX

VIII. Authorized Official

Name: DR. CECIL MARTINDALE BOURNE
Title or Position: OWNER
Credential: MD, FACP
Phone: 361-852-4200