MEDICARE: DR. MOHAMED BOUKADOUM M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	D0023916	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265427819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MOHAMED BOUKADOUM M.D.

Provider Business Mailing Address
First Line	:	1201 SEVEN LOCKS RD
Second Line	:	SUITE 200
City	:	ROCKVILLE
State	:	MD
Zip	:	20854-2931
Country	:	US
Telephone Number	:	301-652-5771
Fax Number	:	301-652-6332

Provider Business Practice Location Address
First Line	:	7600 CARROLL AVE
Second Line	:
City	:	TAKOMA PARK
State	:	MD
Zip	:	20912-6367
Country	:	US
Telephone Number	:	301-891-5106
Fax Number	:	301-891-5383

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	02/17/2009

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