Provider Demographics
NPI:1235168949
Name:BOUTROS, GAMAL S (MD)
Entity Type:Individual
Prefix:
First Name:GAMAL
Middle Name:S
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 1:809 LAMONT ST STE 1
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-5453
Mailing Address - Country:US
Mailing Address - Phone:423-926-1171
Mailing Address - Fax:423-282-8533
Practice Address - Street 1:809 LAMONT ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-5453
Practice Address - Country:US
Practice Address - Phone:423-926-1171
Practice Address - Fax:423-282-8533
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD00000279592084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4037855OtherBCBS
TN721513353OtherUNITED HEALTHCARE
TN0237660KPOtherJOHN DEERE HEALTH
TN3800768Medicaid
TN3800768Medicaid
E14629Medicare UPIN
TNE14629Medicare UPIN