Provider Demographics
NPI:1184310104
Name:SCOURBOUTAKOS, MARY JEAN (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:JEAN
Last Name:SCOURBOUTAKOS
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 HOMESTEAD RD.
Mailing Address - Street 2:
Mailing Address - City:TORONTO
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:M1E 3S1
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:731 WHITE PLAINS RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10473-2631
Practice Address - Country:US
Practice Address - Phone:718-589-8775
Practice Address - Fax:845-633-5766
Is Sole Proprietor?:No
Enumeration Date:2023-04-13
Last Update Date:2025-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY335325207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine