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General NPI Number Information
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NPI Number | 1457177545
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Entity Type | Individual
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Provider Name | DJAMEL BOUAZZA MD
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Gender | Male
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Dates
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Enumeration Date | 11/23/2024
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Last Update Date | 11/23/2024
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Provider Practice Location Address
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Address Line | 6420 CLAYTON RD
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City | SAINT LOUIS
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State | MO
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Zip | 63117-1811
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Country | US
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Telephone | 716-255-6305
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Fax |
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Provider Business Mailing Address
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Address Line | 704 8TH ST
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City | NIAGARA FALLS
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State | NY
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Zip | 14301-1758
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Country | US
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Telephone | 716-255-6305
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 2024032260
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License Number State | MO
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