Provider Demographics
NPI:1366769317
Name:BOUKARROU, LATIFA (MD)
Entity type:Individual
Prefix:
First Name:LATIFA
Middle Name:
Last Name:BOUKARROU
Suffix:
Gender:F
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:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0417
Mailing Address - Country:US
Mailing Address - Phone:772-223-2832
Mailing Address - Fax:772-223-5646
Practice Address - Street 1:1651 SE TIFFANY AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7564
Practice Address - Country:US
Practice Address - Phone:772-419-3810
Practice Address - Fax:772-419-3811
Is Sole Proprietor?:No
Enumeration Date:2010-04-30
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD616030922084N0400X
PAMD4490152084N0400X
WI849962084N0400X
FLME1293522084N0400X
CAA1569922084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLTP618OtherFLORIDA BLUE
PA325959L3FMedicare PIN