Provider Demographics
NPI:1750386041
Name:BOUSTANY, MARC KAMEL (MD)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:KAMEL
Last Name:BOUSTANY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:725 VOLVO PKWY STE 210
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-1621
Mailing Address - Country:US
Mailing Address - Phone:757-261-5000
Mailing Address - Fax:757-962-5610
Practice Address - Street 1:725 VOLVO PKWY STE 210
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-1621
Practice Address - Country:US
Practice Address - Phone:757-261-5000
Practice Address - Fax:757-962-5610
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101221457208600000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007309996Medicaid
VA020001358Medicare ID - Type Unspecified
VA013580S33Medicare PIN
VAG91211Medicare UPIN