Provider Demographics
NPI:1285749549
Name:BOUTT, JULIE A (MD)
Entity type:Individual
Prefix:DR
First Name:JULIE
Middle Name:A
Last Name:BOUTT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4071 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3801
Mailing Address - Country:US
Mailing Address - Phone:810-824-4222
Mailing Address - Fax:810-824-4220
Practice Address - Street 1:4071 24TH AVE
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3801
Practice Address - Country:US
Practice Address - Phone:810-824-4222
Practice Address - Fax:810-824-4220
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJB070145207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1285749549Medicaid
MI383662851OtherPPOM
MI4643528Medicaid
MI0807410461OtherBLUE CROSS/BLUE SHIELD
MI9153443002OtherCIGNA HEALTHCARE HMO
MIH24114Medicare UPIN
MI0N96000Medicare ID - Type Unspecified
MI9153443002OtherCIGNA HEALTHCARE HMO