Provider Demographics
NPI:1366428617
Name:BOUZ, HAISSAM N (MD)
Entity type:Individual
Prefix:
First Name:HAISSAM
Middle Name:N
Last Name:BOUZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3311 PRESCOTT RD
Mailing Address - Street 2:SUITE 314
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3900
Mailing Address - Country:US
Mailing Address - Phone:318-448-8517
Mailing Address - Fax:318-448-8008
Practice Address - Street 1:3311 PRESCOTT RD
Practice Address - Street 2:SUITE 314
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3900
Practice Address - Country:US
Practice Address - Phone:318-448-8517
Practice Address - Fax:318-448-8008
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA013498174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1174661Medicaid
LA1174661Medicaid
LAB62168Medicare UPIN