Provider Demographics
NPI:1952745804
Name:BOUTRIS, NICKOLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:NICKOLAS
Middle Name:
Last Name:BOUTRIS
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 1:13802 CENTERFIELD DR STE 300
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-6043
Mailing Address - Country:US
Mailing Address - Phone:281-737-0999
Mailing Address - Fax:
Practice Address - Street 1:13802 CENTERFIELD DR STE 300
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-6043
Practice Address - Country:US
Practice Address - Phone:281-737-0999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-22
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY292570390200000X
TXS1054207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program