Provider Demographics
NPI:1528562915
Name:BOUTIN, REGINE (MD)
Entity Type:Individual
Prefix:DR
First Name:REGINE
Middle Name:
Last Name:BOUTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 BERGEN ST
Mailing Address - Street 2:UH-I248
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 BERGEN STREET
Practice Address - Street 2:UH-I248
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07101
Practice Address - Country:US
Practice Address - Phone:973-972-6056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program