Provider Demographics
NPI:1164858619
Name:BOU AYACHE, JAD MARWAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JAD
Middle Name:MARWAN
Last Name:BOU AYACHE
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 1:1468 1 GUSTAVE L LEVY PL
Mailing Address - Street 2:APT 5G
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029
Mailing Address - Country:US
Mailing Address - Phone:773-780-4432
Mailing Address - Fax:
Practice Address - Street 1:1468 MADISON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6508
Practice Address - Country:US
Practice Address - Phone:773-780-4432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-16
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2767312085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology