Provider Demographics
NPI:1831152651
Name:LEBOUTILLIER, MARTIN III (MD)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:LEBOUTILLIER
Suffix:III
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:FOURTH & WALNUT STS
Mailing Address - Street 2:2ND FL
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-1281
Mailing Address - Country:US
Mailing Address - Phone:717-270-3751
Mailing Address - Fax:717-270-3754
Practice Address - Street 1:FOURTH & WALNUT STS
Practice Address - Street 2:2ND FL
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-1281
Practice Address - Country:US
Practice Address - Phone:717-270-3751
Practice Address - Fax:717-270-3754
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD065743L208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD058255700Medicaid
PA001708549Medicaid
PA30139141OtherAMERIHEALTH MERCY-WMG
PA976216OtherHIGHMARK BLUE SHIELD
PA1511587OtherGATEWAY
MD058255700Medicaid
PA1511587OtherGATEWAY
PA013897Medicare PIN