Provider Demographics
NPI:1902082753
Name:BOUCHAREB, MAROUANE R (MD)
Entity Type:Individual
Prefix:DR
First Name:MAROUANE
Middle Name:R
Last Name:BOUCHAREB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:12554 RIATA VISTA CIR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78727-6431
Mailing Address - Country:US
Mailing Address - Phone:512-795-5100
Mailing Address - Fax:512-795-5122
Practice Address - Street 1:12554 RIATA VISTA CIR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78727-6431
Practice Address - Country:US
Practice Address - Phone:512-795-5100
Practice Address - Fax:512-795-5122
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA553932085R0202X
IL036.1198712085R0202X
IL0361198712085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology