Healthcare Provider Details

I. General information

NPI: 1871296186
Provider Name (Legal Business Name): OLIVEIA BOUTROS DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2023
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 ESSEX ST STE 405
HACKENSACK NJ
07601-3247
US

IV. Provider business mailing address

211 ESSEX ST STE 405
HACKENSACK NJ
07601-3247
US

V. Phone/Fax

Practice location:
  • Phone: 732-421-6907
  • Fax:
Mailing address:
  • Phone: 732-421-6907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number25MD00390900
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number25MD00390900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: