Provider Demographics
NPI:1568777191
Name:BOUTROS, MARYLISE (MD FRCS)
Entity Type:Individual
Prefix:DR
First Name:MARYLISE
Middle Name:
Last Name:BOUTROS
Suffix:
Gender:F
Credentials:MD FRCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16380 S POST RD
Mailing Address - Street 2:APT 102
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33331-3557
Mailing Address - Country:US
Mailing Address - Phone:954-632-7672
Mailing Address - Fax:
Practice Address - Street 1:2950 CLEVELAND CLINIC BLVD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33331-3609
Practice Address - Country:US
Practice Address - Phone:954-659-5757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-06
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN15351208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery