Healthcare Provider Details

I. General information

NPI: 1437505054
Provider Name (Legal Business Name): ELIZABETH MICHELLE BOUDIAB MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2016
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 SAN PABLO ST
LOS ANGELES CA
90033-5313
US

IV. Provider business mailing address

923 S CREEKVIEW LN
ANAHEIM CA
92808-1444
US

V. Phone/Fax

Practice location:
  • Phone: 734-645-4385
  • Fax:
Mailing address:
  • Phone: 734-645-4385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number4351033486
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number188535
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: