Provider Demographics
NPI:1326015157
Name:BOURGHLI, MAHMOUD
Entity Type:Individual
Prefix:
First Name:MAHMOUD
Middle Name:
Last Name:BOURGHLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12106 CORTEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34613-5514
Mailing Address - Country:US
Mailing Address - Phone:352-597-0022
Mailing Address - Fax:352-597-0086
Practice Address - Street 1:12106 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-5514
Practice Address - Country:US
Practice Address - Phone:352-597-0022
Practice Address - Fax:352-597-0086
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0079929207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG59860OtherMEDICARE
FL112602600Medicaid
FL258702500Medicaid
FL009603900Medicaid