Provider Demographics
NPI:1568427508
Name:BOUTROS, SAMIR BG (MD)
Entity Type:Individual
Prefix:
First Name:SAMIR
Middle Name:BG
Last Name:BOUTROS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:9105 STONY POINT DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23235-1999
Mailing Address - Country:US
Mailing Address - Phone:804-658-6100
Mailing Address - Fax:804-387-6119
Practice Address - Street 1:420 DURANT ST
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970-1614
Practice Address - Country:US
Practice Address - Phone:434-447-3315
Practice Address - Fax:434-447-2540
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2013-03-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0101032398208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007598491Medicaid
VA007598491Medicaid