Provider Demographics
NPI:1376582221
Name:BOUGHABA, DOLLY ALBERT (MD)
Entity Type:Individual
Prefix:
First Name:DOLLY
Middle Name:ALBERT
Last Name:BOUGHABA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 SOUTHWIND LN
Mailing Address - Street 2:
Mailing Address - City:LUDLOW
Mailing Address - State:KY
Mailing Address - Zip Code:41016-1715
Mailing Address - Country:US
Mailing Address - Phone:513-470-2777
Mailing Address - Fax:
Practice Address - Street 1:405 SOUTHWIND LN
Practice Address - Street 2:
Practice Address - City:LUDLOW
Practice Address - State:KY
Practice Address - Zip Code:41016-1715
Practice Address - Country:US
Practice Address - Phone:513-470-2777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01072116A2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64053101Medicaid
IN000000804952OtherANTHEM BCBS
IN200388530Medicaid
OHBO4087041Medicare ID - Type Unspecified