Basic Information
| Provider Information | |||||||||
| NPI: | 1942258991 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOURGEOIS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ELLIOT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6035 FAIRVIEW RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282103256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042953000 | ||||||||
| FaxNumber: | 7042953121 | ||||||||
| Practice Location | |||||||||
| Address1: | 6035 FAIRVIEW RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282103256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042953000 | ||||||||
| FaxNumber: | 7042953121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 10/16/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 25883 | NC | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 11125 | 01 | NC | WELLPATH | OTHER | 1533931002 | 01 | NC | CIGNA | OTHER | 6872 | 01 | NC | PARTNERS | OTHER | 0841480 | 01 | NC | UNITED HEALTHCARE | OTHER | 141004 | 01 | NC | COVENTRY | OTHER | 4068491 | 01 | NC | AETNA | OTHER | 80783 | 01 | SC | CHCCARES OF SC | OTHER | 10482 | 01 | NC | KANAWHA | OTHER | 1963 | 01 | NC | DOCTORS HEALTH PLAN | OTHER | 376565 | 01 | NC | MAMSI | OTHER | 777013 | 01 | SC | WELLCARE | OTHER | 000000282479 | 01 | SC | UNISON HEALTH PLAN OF SC | OTHER | 1533931002 | 01 | NC | CIGNA PRIMEVISION | OTHER | 10610 | 01 | NC | BCBS MEDPOINT | OTHER | 20094032 | 01 | SC | SELECT HEALTH OF SC/FIRST CHOICE | OTHER | N25883 | 05 | SC | MEDICAID | 8917059 | 05 | NC | MEDICAID | 100706 | 01 | NC | WELLNESS | OTHER | 21170 | 01 | NC | MEDCOST | OTHER | 17059 | 01 | NC | BCBS | OTHER | 180019848 | 01 | RAILROAD MEDICARE | OTHER |