Provider Demographics
NPI:1619973096
Name:BOUSTANY, MICHAEL M (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:M
Last Name:BOUSTANY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MOHAMMAD
Other - Middle Name:M
Other - Last Name:BOUSTANY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4605 MACCORKLE AVE SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1311
Mailing Address - Country:US
Mailing Address - Phone:304-414-4800
Mailing Address - Fax:304-414-4801
Practice Address - Street 1:434 DIVISION ST
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309
Practice Address - Country:US
Practice Address - Phone:304-766-7140
Practice Address - Fax:304-766-7180
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV106002086S0129X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6469852500Medicaid
OH2055458Medicaid
WV0127313000Medicaid
KY6469852500Medicaid
D83505Medicare UPIN