Provider Demographics
NPI:1356336358
Name:BOUTON, MICHAEL S (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:BOUTON
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:PO BOX 2010
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58122-0605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-3641
Practice Address - Country:US
Practice Address - Phone:701-234-2251
Practice Address - Fax:701-234-2050
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR4107208600000X
TXG9329208600000X
ND10920208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND14800Medicaid
TXE66990Medicare UPIN
NDN716400Medicare PIN
NDN713623Medicare PIN