Healthcare Provider Details

I. General information

NPI: 1891590980
Provider Name (Legal Business Name): MELISSA BOU JAOUDE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2025
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1446 HARPER ST
AUGUSTA GA
30912-0012
US

IV. Provider business mailing address

636 11TH ST APT 1203
AUGUSTA GA
30901-2178
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-5437
  • Fax:
Mailing address:
  • Phone: 470-736-7306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number17064
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: