Healthcare Provider Details

I. General information

NPI: 1699125880
Provider Name (Legal Business Name): FADY BOUTROS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2016
Last Update Date: 05/18/2020
Certification Date: 05/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S BLDG 53
ORANGE CA
92868-3201
US

IV. Provider business mailing address

12019 HUNTLEY DR
RANCHO CUCAMONGA CA
91739-2543
US

V. Phone/Fax

Practice location:
  • Phone: 909-331-1602
  • Fax:
Mailing address:
  • Phone: 909-331-1602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberA157668
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: