Provider Demographics
NPI:1669479598
Name:BOTROS, MAGED RAMZY (MD)
Entity Type:Individual
Prefix:DR
First Name:MAGED
Middle Name:RAMZY
Last Name:BOTROS
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 1:215 E WATER ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TX
Mailing Address - Zip Code:75951-4440
Mailing Address - Country:US
Mailing Address - Phone:409-384-6835
Mailing Address - Fax:
Practice Address - Street 1:215 E WATER ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951-4440
Practice Address - Country:US
Practice Address - Phone:409-384-6835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG7787208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110637904Medicaid
TX45D0484054OtherCLIA ID NUMBER
TX85650NMedicare ID - Type UnspecifiedMEDICARE PROVIDER ID
TX110637904Medicaid