MEDICARE: JOSHUA P BOUCHER O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2005027604	MO
2	152W00000X	Optometrist	1735	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	152W00000X	OTHER	MO	OPTOMETRY

General Provider Information

NPI Number	:	1134209901
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSHUA P BOUCHER O.D.

Provider Business Mailing Address
First Line	:	1605 NW SUNRIDGE DR
Second Line	:
City	:	BLUE SPRINGS
State	:	MO
Zip	:	64015-3536
Country	:	US
Telephone Number	:	816-721-8169
Fax Number	:

Provider Business Practice Location Address
First Line	:	4027 MILL ST
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64111-3008
Country	:	US
Telephone Number	:	816-561-1665
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/16/2006
Last Update Date	:	03/20/2023

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