Provider Demographics
NPI:1184723819
Name:GHASSIBI, BOUTROS MICHEL (MD)
Entity type:Individual
Prefix:DR
First Name:BOUTROS
Middle Name:MICHEL
Last Name:GHASSIBI
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 1:34 HAVERHILL ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01841-2884
Mailing Address - Country:US
Mailing Address - Phone:978-686-0090
Mailing Address - Fax:978-681-5963
Practice Address - Street 1:34 HAVERHILL ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01841-2884
Practice Address - Country:US
Practice Address - Phone:978-686-0090
Practice Address - Fax:978-681-5963
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA72138207R00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3166724Medicaid
MA3166724Medicaid