Provider Demographics
NPI:1477712024
Name:BOUYARDEN, MICHAEL M (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:M
Last Name:BOUYARDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:MOSTAFA
Other - Last Name:BOUYARDEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5409 BELLAIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:BELLAIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77401-5668
Mailing Address - Country:US
Mailing Address - Phone:504-444-7664
Mailing Address - Fax:
Practice Address - Street 1:5409 BELLAIRE BLVD
Practice Address - Street 2:
Practice Address - City:BELLAIRE
Practice Address - State:TX
Practice Address - Zip Code:77401-3905
Practice Address - Country:US
Practice Address - Phone:504-444-7664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-07
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN4956207RN0300X
282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1083623Medicaid
TXTXB125903Medicare PIN