Provider Demographics
NPI:1114500725
Name:BOUTROS, JOSUE PABLO (MD)
Entity Type:Individual
Prefix:
First Name:JOSUE
Middle Name:PABLO
Last Name:BOUTROS
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 1:13300 SW 47TH ST APT 202
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-5266
Mailing Address - Country:US
Mailing Address - Phone:305-783-9220
Mailing Address - Fax:
Practice Address - Street 1:13300 SW 47TH ST APT 202
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-5266
Practice Address - Country:US
Practice Address - Phone:305-783-9220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJDCATEMP-011588207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJNDJCATEMP-011588OtherNEW JERSEY TEMPORARY EMERGENCY LICENSE OUT OF STATE PRACTITIONER