Provider Demographics
NPI:1265427819
Name:BOUKADOUM, MOHAMED (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMED
Middle Name:
Last Name:BOUKADOUM
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 1:1201 SEVEN LOCKS RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20854-2931
Mailing Address - Country:US
Mailing Address - Phone:301-652-5771
Mailing Address - Fax:301-652-6332
Practice Address - Street 1:7600 CARROLL AVE
Practice Address - Street 2:
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-6367
Practice Address - Country:US
Practice Address - Phone:301-891-5106
Practice Address - Fax:301-891-5383
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00239162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC023155700Medicaid
MD082019S73Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE #