Basic Information
| Provider Information | |||||||||
| NPI: | 1083724256 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUDJENAH | ||||||||
| FirstName: | DJILLALI | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7808 CLODUS FIELDS DR. | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752514914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727701032 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7808 CLODUS FIELDS DR. | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752514914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727701032 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 06/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | CS00211459 | NM | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | ME130416 | 01 | FL | FL LICENSE | OTHER |