Provider Demographics
NPI:1790774081
Name:MUKHTAR-BENGHOZI, TAWFIK M
Entity Type:Individual
Prefix:
First Name:TAWFIK
Middle Name:M
Last Name:MUKHTAR-BENGHOZI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:TAWFIK
Other - Middle Name:
Other - Last Name:BENGHOZI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6213 TENNYSON OAKS LN
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-2759
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5920 COLISEUM BLVD.
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-3714
Practice Address - Country:US
Practice Address - Phone:318-443-9339
Practice Address - Fax:318-443-9116
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08698R2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1926213Medicaid
LA08698ROtherLOUISIANA MEDICAL LICENSE
LA08698ROtherLOUISIANA MEDICAL LICENSE
LA5N513Medicare ID - Type Unspecified
LAE84895Medicare UPIN