Healthcare Provider Details

I. General information

NPI: 1720325574
Provider Name (Legal Business Name): JACQUELINE BOUTROUILLE MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2013
Last Update Date: 03/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7880 N UNIVERSITY DR STE 303
TAMARAC FL
33321-2124
US

IV. Provider business mailing address

7880 N UNIVERSITY DR STE 303
TAMARAC FL
33321-2124
US

V. Phone/Fax

Practice location:
  • Phone: 954-340-3000
  • Fax: 954-636-8407
Mailing address:
  • Phone: 954-340-3000
  • Fax: 954-636-8407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME87029
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberME87029
License Number StateFL

VIII. Authorized Official

Name: JACQUELINE D BOUTROUILLE
Title or Position: OWNER
Credential: MD
Phone: 954-340-3000