Provider Demographics
NPI:1174968069
Name:BOUCHEZ, JONATHAN DANIEL (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DANIEL
Last Name:BOUCHEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 BLYTHE BVLD.
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203
Mailing Address - Country:US
Mailing Address - Phone:704-355-3641
Mailing Address - Fax:
Practice Address - Street 1:1000 BLYTHE BVLD.
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203
Practice Address - Country:US
Practice Address - Phone:704-355-3641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-06
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME147193207R00000X
NC192308208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine