Provider Demographics
NPI:1083109904
Name:BOUTROS, LOURICE (OD)
Entity Type:Individual
Prefix:MISS
First Name:LOURICE
Middle Name:
Last Name:BOUTROS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3235 E COLORADO BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-3837
Mailing Address - Country:US
Mailing Address - Phone:626-765-6634
Mailing Address - Fax:
Practice Address - Street 1:3235 E COLORADO BLVD STE 101
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107
Practice Address - Country:US
Practice Address - Phone:626-765-6634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-22
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33939TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANONEMedicaid