Provider Demographics
NPI:1629036173
Name:BOUTROS, NIDAL
Entity Type:Individual
Prefix:DR
First Name:NIDAL
Middle Name:
Last Name:BOUTROS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:120 HOSPITAL DR
Practice Address - Street 2:SUITE 300
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-9238
Practice Address - Country:US
Practice Address - Phone:417-533-6746
Practice Address - Fax:417-533-6740
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009027847207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1629036173Medicaid
MO1629036173Medicaid