Provider Demographics
NPI:1265535199
Name:BOUTROS, RAJA B (MD)
Entity type:Individual
Prefix:DR
First Name:RAJA
Middle Name:B
Last Name:BOUTROS
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:P.O BOX 2770
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92593-2770
Mailing Address - Country:US
Mailing Address - Phone:951-696-1818
Mailing Address - Fax:951-696-2939
Practice Address - Street 1:25485 MEDICAL CENTER DR
Practice Address - Street 2:#208
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562
Practice Address - Country:US
Practice Address - Phone:951-696-1818
Practice Address - Fax:951-696-2939
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA4997302084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0091910OtherMEDICAL GROUP #
CA90050380OtherPACIFICARE ID#
CA0693834Medicaid
CA00A499730OtherBLUE CROSS ID#
CAZZZ21187ZMedicare ID - Type UnspecifiedGROUP ID
CA00A499730OtherBLUE CROSS ID#