=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609240977
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PSYCH MD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2015
-----------------------------------------------------
Last Update Date | 03/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4425 PLANO PKWY STE 1401
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75010-5036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-888-7711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 867443
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75086-7443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-888-7711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. DJILLALI BOUDJENAH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 917-336-8422
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084B0040X
-----------------------------------------------------
Taxonomy Name | Behavioral Neurology & Neuropsychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------