Provider Demographics
NPI:1437181203
Name:MOUNIR BOUTROS MD INC
Entity Type:Organization
Organization Name:MOUNIR BOUTROS MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOUNIR
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUTROS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-824-2288
Mailing Address - Street 1:5951 RENAISSANCE PL
Mailing Address - Street 2:
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:
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35062133B174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHF51908Medicare UPIN