Provider Demographics
NPI:1366530131
Name:BOUTROS, AYMAN (MD)
Entity type:Individual
Prefix:
First Name:AYMAN
Middle Name:
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 1:224-D CORNWALL STREET, NW, SUITE 403
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:21475 RIDGETOP CIR
Practice Address - Street 2:SUITE 300
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20166-6580
Practice Address - Country:US
Practice Address - Phone:703-430-4400
Practice Address - Fax:703-430-4130
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101043806207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1366530131Medicaid
VA30015510290001Medicaid
VA180000265Medicare ID - Type UnspecifiedTRAILBLAZERS (CENTRAL VA)
VA000C43N63Medicare ID - Type UnspecifiedTRAILBLAZER N. V, DEL, MD
VA0858550001Medicare NSC
MD8956502-00Medicaid
VA180007056Medicare ID - Type UnspecifiedRAILROAD MEDICARE
VA6305181Medicaid
MD8956502-02Medicaid
VA000C43N63Medicare ID - Type UnspecifiedTRAILBLAZER N. V, DEL, MD
VA180000265Medicare ID - Type UnspecifiedTRAILBLAZERS (CENTRAL VA)
MD8956502-03Medicaid
WV95149000Medicaid
MD8956502-01Medicaid
VA053766OtherANTHEM/HEALTHKEEPERS
VA112108OtherANTHEM/HEALTHKEEPERS
E02477Medicare UPIN
VA0858550001Medicare NSC