Provider Demographics
NPI:1497785281
Name:BOUTROS, MAGED T (MD)
Entity Type:Individual
Prefix:
First Name:MAGED
Middle Name:T
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 1:1033 ROUTE 46 EAST
Mailing Address - Street 2:SUITE G1
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013
Mailing Address - Country:US
Mailing Address - Phone:973-777-3711
Mailing Address - Fax:973-472-3938
Practice Address - Street 1:1033 ROUTE 46 STE G1
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-2448
Practice Address - Country:US
Practice Address - Phone:973-429-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08097300207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0138808OtherGHI
NJ0111759Medicaid
NJP00688848OtherRAILROAD MEDICARE-HIGHLAND PHYS SRVS
NJP00359479OtherRAILROAD
NJP00359479OtherRAILROAD
NJ0138808OtherGHI
NJI57371Medicare UPIN
NJ102784SNYMedicare PIN