Provider Demographics
NPI:1174574479
Name:BOUTIETTE, LON A (MD)
Entity type:Individual
Prefix:DR
First Name:LON
Middle Name:A
Last Name:BOUTIETTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 88452
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60680-1452
Mailing Address - Country:US
Mailing Address - Phone:205-437-6098
Mailing Address - Fax:205-437-5998
Practice Address - Street 1:1000 MAR WALT DR
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6708
Practice Address - Country:US
Practice Address - Phone:850-863-7607
Practice Address - Fax:205-437-5998
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51154207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL063236800Medicaid
AL059184932OtherBCBS PROVIDER NUMBER
FL04698OtherBCBS PROVIDER NUMBER
AL059184934OtherBCBS PROVIDER NUMBER
AL059184933OtherBCBS PROVIDER NUMBER
FL04698TMedicare PIN
FL04698FMedicare PIN
FL04698EMedicare PIN
FL04698OtherBCBS PROVIDER NUMBER
FLD44896Medicare UPIN