Provider Demographics
NPI:1518917632
Name:BOUSTANI, MARIA RIZKALLAH (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIA
Middle Name:RIZKALLAH
Last Name:BOUSTANI
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 1:421 CARRIAGE DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-2805
Mailing Address - Country:US
Mailing Address - Phone:304-256-0242
Mailing Address - Fax:304-256-0244
Practice Address - Street 1:421 CARRIAGE DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2805
Practice Address - Country:US
Practice Address - Phone:304-256-0242
Practice Address - Fax:304-256-0244
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18402207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001711048OtherBLUE CROSS BLUE SHIELD
WV1801602000Medicare ID - Type Unspecified
WV001711048OtherBLUE CROSS BLUE SHIELD
WVF09090Medicare UPIN