Healthcare Provider Details

I. General information

NPI: 1518904093
Provider Name (Legal Business Name): NASHAAT N BOUTROS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 04/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 LAKE COOK RD STE 2
DEERFIELD IL
60015
US

IV. Provider business mailing address

440 LAKE COOK RD STE 2
DEERFIELD IL
60015-5263
US

V. Phone/Fax

Practice location:
  • Phone: 847-945-6463
  • Fax: 847-945-6469
Mailing address:
  • Phone: 847-945-6463
  • Fax: 847-945-6469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036.061302
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: