Provider Demographics
NPI:1942243563
Name:BOUTROS, JASON K (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:K
Last Name:BOUTROS
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 1:2554 E WASHINGTON BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-1445
Mailing Address - Country:US
Mailing Address - Phone:626-798-8923
Mailing Address - Fax:626-798-0258
Practice Address - Street 1:2554 E WASHINGTON BLVD
Practice Address - Street 2:STE A
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-1445
Practice Address - Country:US
Practice Address - Phone:626-798-8923
Practice Address - Fax:626-798-0258
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42891174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A42891Medicaid
CAA42891OtherLICENSE NO.
CA00A42891Medicaid
CAA42891OtherLICENSE NO.
CAC04014Medicare UPIN