Provider Demographics
NPI:1326094723
Name:BOUKMAN, IMHOTEP (MD)
Entity Type:Individual
Prefix:
First Name:IMHOTEP
Middle Name:
Last Name:BOUKMAN
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 1:100 SENTARA CIR RM 2C
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-5713
Mailing Address - Country:US
Mailing Address - Phone:757-984-7217
Mailing Address - Fax:757-984-7210
Practice Address - Street 1:100 SENTARA CIR RM 2C
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-5713
Practice Address - Country:US
Practice Address - Phone:757-984-7217
Practice Address - Fax:757-984-7210
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD418363207R00000X
VA0101263610208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001901656Medicaid
PAH55393Medicare UPIN