Healthcare Provider Details

I. General information

NPI: 1184310104
Provider Name (Legal Business Name): MARY JEAN SCOURBOUTAKOS MD, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2023
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 WHITE PLAINS RD
BRONX NY
10473-2631
US

IV. Provider business mailing address

107 HOMESTEAD RD.
TORONTO ONTARIO
M1E 3S1
CA

V. Phone/Fax

Practice location:
  • Phone: 718-589-8775
  • Fax: 845-633-5766
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number335325
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: