Provider Demographics
NPI:1770309767
Name:BOUFETTA, MERIEM ELSAYED I (MS)
Entity type:Individual
Prefix:MS
First Name:MERIEM
Middle Name:ELSAYED
Last Name:BOUFETTA
Suffix:I
Gender:F
Credentials:MS
Other - Prefix:MR
Other - First Name:MAHMOUD
Other - Middle Name:GOMAA ABDELMEGUID
Other - Last Name:ELSAYED
Other - Suffix:I
Other - Last Name Type:Other Name
Other - Credentials:MR
Mailing Address - Street 1:5024 W WINONA ST APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-2318
Mailing Address - Country:US
Mailing Address - Phone:773-818-1875
Mailing Address - Fax:
Practice Address - Street 1:5024 W WINONA ST APT 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-2318
Practice Address - Country:US
Practice Address - Phone:773-818-1875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL15476524172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver