Provider Demographics
NPI:1336134089
Name:BOUTRY, DONALD ALAN (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:ALAN
Last Name:BOUTRY
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 1:314 MARTIN LUTHER KING JR WAY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4250
Mailing Address - Country:US
Mailing Address - Phone:253-403-5432
Mailing Address - Fax:
Practice Address - Street 1:314 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:SUITE 104
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4250
Practice Address - Country:US
Practice Address - Phone:253-403-5432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00025494207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7096845Medicaid
WAA08874Medicare UPIN
WAGAB11226Medicare PIN