Provider Demographics
NPI:1245595602
Name:BOUTROS, SAMIR SAMUEL (MD)
Entity type:Individual
Prefix:DR
First Name:SAMIR
Middle Name:SAMUEL
Last Name:BOUTROS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:13935 COOLIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:BRIARWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435-1118
Mailing Address - Country:US
Mailing Address - Phone:718-216-3166
Mailing Address - Fax:718-649-7040
Practice Address - Street 1:2400 LINDEN BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11208-4830
Practice Address - Country:US
Practice Address - Phone:718-257-5800
Practice Address - Fax:718-649-7040
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY004090207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine