Provider Demographics
NPI:1992861116
Name:BOTROUS, SUZANNE W (MD)
Entity Type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:W
Last Name:BOTROUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 CENTRAL AVE STE 308
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018-3318
Mailing Address - Country:US
Mailing Address - Phone:973-678-3776
Mailing Address - Fax:973-678-6065
Practice Address - Street 1:185 CENTRAL AVE STE 308
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-3318
Practice Address - Country:US
Practice Address - Phone:973-678-3776
Practice Address - Fax:973-678-6065
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA061272261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6381006Medicaid