Provider Demographics
NPI:1588455992
Name:BOUIDIA, ISSAM DALE
Entity type:Individual
Prefix:
First Name:ISSAM
Middle Name:DALE
Last Name:BOUIDIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5066 ROMAINE ST APT 7
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-2599
Mailing Address - Country:US
Mailing Address - Phone:213-846-6581
Mailing Address - Fax:
Practice Address - Street 1:5066 ROMAINE ST APT 7
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-2599
Practice Address - Country:US
Practice Address - Phone:213-846-6581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-14
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker