Provider Demographics
NPI:1861692857
Name:BOUCHARD, BRYAN EDWARD (IDC)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:EDWARD
Last Name:BOUCHARD
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 BRYNN MARR RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-7608
Mailing Address - Country:US
Mailing Address - Phone:910-346-1512
Mailing Address - Fax:
Practice Address - Street 1:2ND TANK BATTALION
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542
Practice Address - Country:US
Practice Address - Phone:910-449-9092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman