Provider Demographics
NPI:1235105941
Name:BOUTROS, MOUNIR (MD)
Entity Type:Individual
Prefix:DR
First Name:MOUNIR
Middle Name:
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 1:5951 RENAISSANCE PL
Mailing Address - Street 2:SUITE C
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4722
Mailing Address - Country:US
Mailing Address - Phone:419-824-2288
Mailing Address - Fax:419-824-2287
Practice Address - Street 1:5951 RENAISSANCE PL
Practice Address - Street 2:SUITE C
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4722
Practice Address - Country:US
Practice Address - Phone:419-824-2288
Practice Address - Fax:419-824-2287
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35062133B207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHF51908Medicare UPIN