1043388788 NPI number — JOSE ANTONIO BOUFFARD M.D.

Table of content: JOSE ANTONIO BOUFFARD M.D. (NPI 1043388788)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043388788 NPI number — JOSE ANTONIO BOUFFARD M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOUFFARD
Provider First Name:
JOSE
Provider Middle Name:
ANTONIO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOUFFARD
Provider Other First Name:
J
Provider Other Middle Name:
ANTONIO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1043388788
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
261 MACK AVE
Provider Second Line Business Mailing Address:
ROOM 215
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48201-2417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-966-2539
Provider Business Mailing Address Fax Number:
313-993-2630

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
261 MACK AVE
Provider Second Line Business Practice Location Address:
ROOM 215
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48201-2417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-966-2539
Provider Business Practice Location Address Fax Number:
313-993-2630
Provider Enumeration Date:
12/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207UN0902X , with the licence number:  4301044748 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: JB044748 . This is a "STATE LICENSURE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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