Basic Information
Provider Information | |||||||||
NPI: | 1164407532 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DOUMET | ||||||||
FirstName: | BOUCHRA | ||||||||
MiddleName: | S | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 333 N SUMMIT ST FL 7 | ||||||||
Address2: |   | ||||||||
City: | TOLEDO | ||||||||
State: | OH | ||||||||
PostalCode: | 436041531 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5675850380 | ||||||||
FaxNumber: | 5675850381 | ||||||||
Practice Location | |||||||||
Address1: | 6175 LEVIS COMMONS BLVD # 104 | ||||||||
Address2: |   | ||||||||
City: | PERRYSBURG | ||||||||
State: | OH | ||||||||
PostalCode: | 43551 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5675850380 | ||||||||
FaxNumber: | 5675850381 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/08/2005 | ||||||||
LastUpdateDate: | 11/23/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/23/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35083437 | OH | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | P00358429 | 01 | OH | RAILROAD MEDICARE | OTHER | 2524316 | 05 | OH |   | MEDICAID |