Basic Information
Provider Information | |||||||||
NPI: | 1952393084 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOURQUE | ||||||||
FirstName: | DANIEL | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 435 HEYMANN BLVD | ||||||||
Address2: |   | ||||||||
City: | LAFAYETTE | ||||||||
State: | LA | ||||||||
PostalCode: | 705032616 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3372343344 | ||||||||
FaxNumber: | 3372343352 | ||||||||
Practice Location | |||||||||
Address1: | 435 HEYMANN BLVD | ||||||||
Address2: |   | ||||||||
City: | LAFAYETTE | ||||||||
State: | LA | ||||||||
PostalCode: | 705032616 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3372343344 | ||||||||
FaxNumber: | 3372343352 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/16/2005 | ||||||||
LastUpdateDate: | 11/09/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 03/22/2006 | ||||||||
NPIReactivationDate: | 04/18/2006 | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 016161 | LA | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 1952383084 | 01 | LA | INDIVIDUAL NPI | OTHER | 1659688489 | 01 | LA | GROUP NPI | OTHER | 1345580 | 05 | LA |   | MEDICAID | 5L938DQ00 | 01 | LA | INDIVIDUAL PTAN | OTHER | 5DQ00 | 01 | LA | GROUP PTAN | OTHER |