Healthcare Provider Details

I. General information

NPI: 1679740302
Provider Name (Legal Business Name): BASSEM MOURAD BOUTROS SAMAAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2008
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9126 GREAT HERON CIR
ORLANDO FL
32836-5487
US

IV. Provider business mailing address

9126 GREAT HERON CIR
ORLANDO FL
32836-5487
US

V. Phone/Fax

Practice location:
  • Phone: 201-914-2493
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number260585
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME114899
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: