Provider Demographics
NPI:1700992674
Name:BOUTROS, MARK SAMIR (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:SAMIR
Last Name:BOUTROS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 S EAST ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-1534
Mailing Address - Country:US
Mailing Address - Phone:317-991-7600
Mailing Address - Fax:317-215-7038
Practice Address - Street 1:4200 S EAST ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227
Practice Address - Country:US
Practice Address - Phone:317-991-7600
Practice Address - Fax:317-215-7038
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101265722207R00000X
IN01070720A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN065940009Medicare PIN