Basic Information
| Provider Information | |||||||||
| NPI: | 1295732352 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOUTROS | ||||||||
| FirstName: | DINA | ||||||||
| MiddleName: | YOUSEFF | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3562 RIDGE PARK DR | ||||||||
| Address2: | STE. A | ||||||||
| City: | FAIRLAWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443339294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306640767 | ||||||||
| FaxNumber: | 3306640766 | ||||||||
| Practice Location | |||||||||
| Address1: | 3562 RIDGE PARK DR | ||||||||
| Address2: | STE. A | ||||||||
| City: | FAIRLAWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443339294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306640767 | ||||||||
| FaxNumber: | 3306640766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2005 | ||||||||
| LastUpdateDate: | 10/11/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 35073803 | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 2340087 | 05 | OH | MEDICAID | 2551671 | 01 | OH | PARTNERS PHYSICIAN GROUP MEDICAID GROUP # | OTHER | 9338635 | 01 | OH | PARTNERS PHYSICIAN GROUP MEDICARE GROUP # | OTHER | 1841239274 | 01 | OH | PARTNERS PHYSICIAN GROUP TYPE 2 NPI # | OTHER |