Provider Demographics
NPI:1730767286
Name:BOUAZIZI, ELLEN (MD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:BOUAZIZI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:
Other - Last Name:CEALEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3535 W 13 MILE RD
Mailing Address - Street 2:LL-SOUTH CLINIC
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6770
Mailing Address - Country:US
Mailing Address - Phone:248-551-3000
Mailing Address - Fax:248-551-2032
Practice Address - Street 1:3535 W 13 MILE RD
Practice Address - Street 2:LL- SOUTH CLINIC
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6770
Practice Address - Country:US
Practice Address - Phone:248-551-3000
Practice Address - Fax:248-551-2032
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2023-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351049822208000000X, 207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program