=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790774081
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAWFIK M. MUKHTAR-BENGHOZI
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2005
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5920 COLISEUM BLVD.
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71303-3714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-443-9339
-----------------------------------------------------
Fax | 318-443-9116
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6213 TENNYSON OAKS LN
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71301-2759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0802X
-----------------------------------------------------
Taxonomy Name | Addiction Psychiatry Physician
-----------------------------------------------------
License Number | 08698R
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------