Provider Demographics
NPI:1508241209
Name:BOU GHANNAM, ALAA (MD)
Entity Type:Individual
Prefix:
First Name:ALAA
Middle Name:
Last Name:BOU GHANNAM
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 1:2131 LAWRENCE ST APT 606
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-2896
Mailing Address - Country:US
Mailing Address - Phone:202-531-5858
Mailing Address - Fax:
Practice Address - Street 1:13001 E 17TH PL
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-2570
Practice Address - Country:US
Practice Address - Phone:303-724-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-23
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMTL002799207W00000X
VA0116028520207W00000X
COTL.0005920207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology