1790774081 NPI number — TAWFIK M. MUKHTAR-BENGHOZI

Table of content: TAWFIK M. MUKHTAR-BENGHOZI (NPI 1790774081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790774081 NPI number — TAWFIK M. MUKHTAR-BENGHOZI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUKHTAR-BENGHOZI
Provider First Name:
TAWFIK
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BENGHOZI
Provider Other First Name:
TAWFIK
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1790774081
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6213 TENNYSON OAKS LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71301-2759
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5920 COLISEUM BLVD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71303-3714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-443-9339
Provider Business Practice Location Address Fax Number:
318-443-9116
Provider Enumeration Date:
10/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0802X , with the licence number:  08698R , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1926213 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08698R . This is a "LOUISIANA MEDICAL LICENSE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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