Healthcare Provider Details

I. General information

NPI: 1063614352
Provider Name (Legal Business Name): ELIZABETH ANN BARKOUDAH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 04/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE FEGAN 11
BOSTON MA
02115-5724
US

IV. Provider business mailing address

11 GROVENOR RD APT 3
JAMAICA PLAIN MA
02130-2515
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-6388
  • Fax:
Mailing address:
  • Phone: 617-435-9108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number231486
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number231486
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number231486
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: