Provider Demographics
NPI:1700952827
Name:BOUTROS, ADEL (MD)
Entity Type:Individual
Prefix:DR
First Name:ADEL
Middle Name:
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:PO BOX 8095
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92728-8095
Mailing Address - Country:US
Mailing Address - Phone:949-951-9399
Mailing Address - Fax:949-951-9403
Practice Address - Street 1:22611 LAKE FOREST DR
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-1700
Practice Address - Country:US
Practice Address - Phone:949-951-9399
Practice Address - Fax:949-951-9403
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA47792207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A477921Medicaid
CAA47792OtherSTATE LICENSE
CA00A477921Medicaid
CAE92511Medicare UPIN