Provider Demographics
NPI:1619399060
Name:BOUTROUS, MINA (MD)
Entity Type:Individual
Prefix:DR
First Name:MINA
Middle Name:
Last Name:BOUTROUS
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 1:6400 FANNIN ST
Mailing Address - Street 2:SUITE 2850
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-1521
Mailing Address - Country:US
Mailing Address - Phone:713-486-5100
Mailing Address - Fax:
Practice Address - Street 1:6400 FANNIN ST
Practice Address - Street 2:SUITE 2850
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1521
Practice Address - Country:US
Practice Address - Phone:713-486-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-19
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT0644962086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program