Basic Information
Provider Information
NPI: 1003004532
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BOUCHARD
FirstName: DONALD
MiddleName: FRANCIS
NamePrefix: MR.
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 17 WATERHOUSE LN
Address2: GOLDSTAR MEDICAL SERVICES, INC.
City: CHESTER
State: CT
PostalCode: 06412
CountryCode: US
TelephoneNumber: 8605264333
FaxNumber: 8605264333
Practice Location
Address1: 17 WATERHOUSE LN
Address2:  
City: CHESTER
State: CT
PostalCode: 064121267
CountryCode: US
TelephoneNumber: 8605264333
FaxNumber: 8605264333
Other Information
ProviderEnumerationDate: 10/10/2007
LastUpdateDate: 10/10/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
171W00000X CTY Other Service ProvidersContractor 

ID Information
IDTypeStateIssuerDescription
12DME0363CT0201CTANTHEM BLUE CROSS CTOTHER
GO37625401CTBLUE CROSS/SHIELD MAOTHER


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