Provider Demographics
NPI:1144287681
Name:BOURNIQUE, VINCENT M (MD)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:M
Last Name:BOURNIQUE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1600 S 20TH AVE
Mailing Address - Street 2:#350
Mailing Address - City:SAFFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85546-4011
Mailing Address - Country:US
Mailing Address - Phone:928-348-4037
Mailing Address - Fax:855-876-8606
Practice Address - Street 1:8075 N SHADELAND AVE
Practice Address - Street 2:#350
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2693
Practice Address - Country:US
Practice Address - Phone:317-678-3900
Practice Address - Fax:317-841-0395
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2017-01-18
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Provider Licenses
StateLicense IDTaxonomies
IN01029804A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10385690Medicaid
IN10385690Medicaid
C78698Medicare UPIN
IN218650GMedicare PIN