Basic Information
| Provider Information | |||||||||
| NPI: | 1316390990 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOUCHER | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 WEST HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | FORT GORDON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309055650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067871648 | ||||||||
| FaxNumber: | 7067877201 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 EAST HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | FORT GORDON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309055650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067871648 | ||||||||
| FaxNumber: | 7067871745 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2016 | ||||||||
| LastUpdateDate: | 09/26/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 02005183A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.