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General NPI Number Information
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NPI Number | 1184310104
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Entity Type | Individual
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Provider Name | MARY JEAN SCOURBOUTAKOS MD, PHD
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Gender | Female
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Dates
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Enumeration Date | 04/13/2023
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Last Update Date | 07/23/2025
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Provider Practice Location Address
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Address Line | 731 WHITE PLAINS RD
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City | BRONX
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State | NY
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Zip | 10473-2631
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Country | US
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Telephone | 718-589-8775
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Fax | 845-633-5766
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Provider Business Mailing Address
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Address Line | 107 HOMESTEAD RD.
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City | TORONTO
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State | ONTARIO
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Zip | M1E 3S1
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Country | CA
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 335325
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License Number State | NY
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