Provider Demographics
NPI:1427225788
Name:BOUALLALI, HIND (MD)
Entity Type:Individual
Prefix:DR
First Name:HIND
Middle Name:
Last Name:BOUALLALI
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 1:1135 SECRETARIAT CT
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:VA
Mailing Address - Zip Code:22066-1715
Mailing Address - Country:US
Mailing Address - Phone:917-664-1143
Mailing Address - Fax:
Practice Address - Street 1:20745 WILLIAMSPORT PL STE 340
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-6520
Practice Address - Country:US
Practice Address - Phone:917-664-1143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY262731208000000X, 261QP2300X
VA0101265045208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03127837Medicaid