Provider Demographics
NPI:1912905340
Name:BOUHACHEM, ALEX (DPM)
Entity Type:Individual
Prefix:DR
First Name:ALEX
Middle Name:
Last Name:BOUHACHEM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1813 N ROSEVERE AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48128-1242
Mailing Address - Country:US
Mailing Address - Phone:734-895-4530
Mailing Address - Fax:313-447-3234
Practice Address - Street 1:10801 W WARREN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-1191
Practice Address - Country:US
Practice Address - Phone:734-895-4530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002050213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI134918586Medicaid
MI0P30250Medicare PIN