Provider Demographics
NPI:1053532580
Name:JASON K BOUTROS M D INC
Entity type:Organization
Organization Name:JASON K BOUTROS M D INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-798-8923
Mailing Address - Street 1:2750 E WASHINGTON BLVD
Mailing Address - Street 2:SUITE 260
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-1448
Mailing Address - Country:US
Mailing Address - Phone:626-798-8923
Mailing Address - Fax:626-798-0258
Practice Address - Street 1:2750 E WASHINGTON BLVD
Practice Address - Street 2:SUITE 260
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-1448
Practice Address - Country:US
Practice Address - Phone:626-798-8923
Practice Address - Fax:626-798-0258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42891207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0076360Medicaid
CAW13909Medicare ID - Type Unspecified
CAW13909AMedicare PIN
CAGR0076360Medicaid