Provider Demographics
NPI:1255376455
Name:BOUDJOUK, JASON BASHIR (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:BASHIR
Last Name:BOUDJOUK
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 1:1 ASHLEY DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-1434
Mailing Address - Country:US
Mailing Address - Phone:401-334-3754
Mailing Address - Fax:
Practice Address - Street 1:190 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-2430
Practice Address - Country:US
Practice Address - Phone:401-921-5970
Practice Address - Fax:401-921-5973
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD12133207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1396864542OtherNPI KENT HOSPITAL PBO
RI119004931Medicare PIN