Provider Demographics
NPI:1043204134
Name:ZEIDAN, BOUTROS (MD)
Entity Type:Individual
Prefix:
First Name:BOUTROS
Middle Name:
Last Name:ZEIDAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 LOCUST ST
Mailing Address - Street 2:SUITE 5B
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15901-1651
Mailing Address - Country:US
Mailing Address - Phone:814-535-2030
Mailing Address - Fax:814-535-2031
Practice Address - Street 1:315 LOCUST ST
Practice Address - Street 2:SUITE 5B
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15901-1651
Practice Address - Country:US
Practice Address - Phone:814-535-2030
Practice Address - Fax:814-535-2031
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD064590L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA161817OtherHIGHMARK BLUE SHIELD
PA99630OtherTHREE RIVERS HEALTH PLAN
PA1507228OtherGATEWAY
PA0017225930005Medicaid
PA21200Medicare ID - Type UnspecifiedMEDICARE
PA0017225930005Medicaid
PA99630OtherTHREE RIVERS HEALTH PLAN